Up@dawn 2.0

Monday, December 9, 2013

Enhanced Medical Care for an Annual Fee

"creating a science-fiction metropolis in which only the best-off remain, living the longest and healthiest lives..." Enhanced Medical Care for an Annual Fee - NYTimes.com: 'via Blog this'

Also of interest:

EDITORIAL-When Bishops Direct Medical Care
A lawsuit filed on behalf of a Michigan woman highlights the conflict between religious mandates and a hospital’s duty.
Exercise as Potent Medicine-"results consistently showed that drugs and exercise produced the same results"

F.D.A. Questions Safety of Antibacterial Soaps

The agency said it was taking the step after some data suggested problems like bacterial resistance and hormonal effects.

Glaxo Says It Will Stop Paying Doctors to Promote Drugs By KATIE THOMAS 

The announcement, an apparent first for a major drug company, would end a common practice that is criticized for posing a conflict of interest.

Should We Toss Our Vitamin Pills? By RONI CARYN RABIN 

Remember how good we thought they were supposed to be for us? Well, not really, some doctors say, with one medical journal editorial arguing that they were a waste of money.

Three Biological Parents and a Baby By KAREN WEINTRAUB

Progress in fertilization techniques intended to avoid birth defects has rekindled a debate on genetics. Mixing the DNA of two women in a single baby can’t be ethical, one critic says.

By SUSANNAH MEADOWSA Disability, and a Mother’s Embrace

In her memoir, an Upper West Side intellectual whose son has Down syndrome attempts to set people straight: it is a disability, not a tragedy.

What Price Love? By JOYCE WADLER

Aids like the little blue pills are so expensive – and coverage so limited — that calculations must be made.

No, There Won’t Be a Doctor Shortage By SCOTT GOTTLIEB and EZEKIEL J. EMANUEL

There are good reasons to be skeptical of predictions of doctor shortages in 10 years.

Are Today’s New Surgeons Unprepared?



Can asking patients to consider costs actually help make affordable, high-quality health care more available?

Friday, December 6, 2013

Friday, November 15, 2013

Bioethics texts, Spring 2014

UPDATE, Nov.27: We'll begin with these, adding more if time and inclination permit:  

Bioethics: The Basics by Campbell, Alastair V. - ISBN-10: 0415504082

Humanity Enhanced: Genetic Choice and the Challenge for Liberal Democracies (Basic Bioethics) by Russell Blackford ISBN-10: 0262026619
Life at the Speed of Light: From the Double Helix to the Dawn of Digital Life by Venter, J. Craig -  ISBN 0670025402
   Generosity: An Enhancement Paperback – Bargain Price by Richard Powers  - ISBN 0312429754
Still pondering text selections for our Spring '14 Bioethics class, which was just added to the course schedule at the 11th hour. Possibilities include either (1) a compendious and expensive textbook OR (2) three (or more) smaller and cheaper trade publications. If members of the course have a preference, please reply to this post ASAP. My inclination (being a cheapskate) is to go with option 2, and supplement with Internet-available sources. But what's yours?

The leading "compendious and expensive" candidates:

Bioethics: Principles, Issues and Cases, 2nd Edition by Lewis Vaughn (Sep 12, 2012) $81.50
Principles of Biomedical Ethics (Principles of Biomedical Ethics (Beauchamp)) [Paperback] $62.35
Arguing About Bioethics (Arguing About Philosophy) by Holland, Stephen (Jan 25, 2013) $40.00 Kindle Edition $47.50 paper

The Cambridge Textbook of Bioethics by Peter A. Singer and A. M. Viens (Mar 3, 2008) Paperback $79.66  $61.60 Kindle Edition

Some "smaller and cheaper" alternatives:

Bioethics: The Basics by Campbell, Alastair V. (May 29, 2013) $13.77 Kindle Edition Auto-delivered wirelessly $21.95 $19.00 Paperback  

Humanity Enhanced: Genetic Choice and the Challenge for Liberal Democracies (Basic Bioethics) Hardcover by Russell Blackford  (Author) Hardcover  $27.00
Life at the Speed of Light: From the Double Helix to the Dawn of Digital Life by Venter, J. Craig (Oct 17, 2013) $10.99 Kindle Edition $26.95 $18.84 Hardcover
The Case against Perfection: Ethics in the Age of Genetic Engineering by Sandel, Michael J. (May 1, 2007) $9.99 Kindle Edition Auto-delivered wirelessly $15.00 $13.96 Paperback 
Enhancing Evolution: The Ethical Case for Making Better People Paperback $14.68 by John Harris Kindle$10.49
Limits to Medicine: Medical Nemesis, the Expropriation of Health Paperback $14 by Ivan Illich 
The Immortal Life of Henrietta Lacks by Skloot, Rebecca (Jun 4, 2010) $8.99 Kindle Edition Whispersync for Voice-ready $16.00 $9.78 Paperback

Complications: A Surgeon's Notes on an Imperfect Science [Kindle Edition] Atul Gawande 

Print List Price:$16.00
Kindle Price:$8.89 
           The Checklist Manifesto: How to Get Things Right [Kindle Edition] Atul Gawande 
Print List Price:$16.00
Kindle Price:$8.89
 How Doctors Think [Kindle Edition] Jerome Groopman 

Digital List Price:$15.95 What's this? 
Print List Price:$15.95
Kindle Price:$8.61

Everything I Learned in Medical School: Besides All the Book Stuff [Kindle Edition]

Sujay Kansagra 
Digital List Price:$6.99 What's this? 
Print List Price:$13.99
Kindle Price:$5.38

 Helping, Healing, Caring: Memoir of a Nurse [Kindle Edition]

Digital List Price:$3.99 What's this? 
Print List Price:$14.85
Kindle Price:$3.99

Monday, August 5, 2013

In Need of a New Hip, but Priced Out of the U.S.

As an addicted daily walker and the owner of a pair of sporadically arthritic hips, a trip to Belgium may be in my future.
“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”
As the United States struggles to rein in its growing $2.7 trillion health care bill, the cost of medical devices like joint implants, pacemakers and artificial urinary valves offers a cautionary tale. Like many medical products or procedures, they cost far more in the United States than in many other developed countries.
Makers of artificial implants — the biggest single cost of most joint replacement surgeries — have proved particularly adept at commanding inflated prices, according to health economists. Multiple intermediaries then mark up the charges. While Mr. Shopenn was offered an implant in the United States for $13,000, many privately insured patients are billed two to nearly three times that amount..." In Need of a New Hip, but Priced Out of the U.S. - NYTimes.com

Monday, July 22, 2013

A bioethicist confronts her convictions

Real life has a way of challenging even our deepest assumptions and our most committed abstractions. The right to die and the love of life are intertwined. Nobody should speak for anybody else, when choices must be made. Remarkable story.
“A person should be accorded the right to live his or her life as they see fit (provided, of course, that this does not significantly harm others), and that includes the very end of their life,” Peggy Battin wrote in one of her nearly 40 journal articles on this subject. “That’s just the way I see it.”
That’s the way she saw it after [her husband] Brooke’s accident too, but with a new spiky awareness of what it means to choose death. Scholarly thought experiments were one thing, but this was a man she adored — a man with whom she shared a rich and passionate life for more than 30 years — who was now physically devastated but still free, as she knew he had to be, to make a choice that would cause her anguish. “It is not just about terminally ill people in general in a kind of abstract way now..."
A Life-or-Death Situation - NYTimes.com

Friday, June 28, 2013


Looking forward to Michael Pollan's and Mark Bittman's responses to this Atlantic assault on "wholesomeness":
If the most-influential voices in our food culture today get their way, we will achieve a genuine food revolution. Too bad it would be one tailored to the dubious health fantasies of a small, elite minority. And too bad it would largely exclude the obese masses, who would continue to sicken and die early. Despite the best efforts of a small army of wholesome-food heroes, there is no reasonable scenario under which these foods could become cheap and plentiful enough to serve as the core diet for most of the obese population—even in the unlikely case that your typical junk-food eater would be willing and able to break lifelong habits to embrace kale and yellow beets. And many of the dishes glorified by the wholesome-food movement are, in any case, as caloric and obesogenic as anything served in a Burger King...
How Junk Food Can End Obesity - David H. Freedman - The Atlantic

Deena Shanker responds:
...Making the case that the “science of processed food can save us – if the foodies will get out of the way,” Freedman operates under the mistaken premise that our food system’s only major consequence is a rise in obesity, ignoring other pesky health issues like our population’s growing resistance to medicationearly onset puberty, and cancer; the serious environmental impacts of an industrialized food system (and its direct effect on our health); as well as the basic moral failings of factory farming (to put it lightly). He also uses a series of misinterpretations, false comparisons, “rough calculations,” approximations and at least one “not exactly scientific study,” to peddle the best PR Big Food has gotten since it had the Big-Mac-scarfing Bill Clinton in the White House... Salon.com 


Friday, May 10, 2013

Good grief

Smart's overrated

Health Care: Radiance's Reform

As Glenn McGee points out in Case 45, we need to change the way we look at healthcare. However, this book was published back in 1995. What he framed as a warning of future comings is now on our doorstep.   The first thing he brings to light is that fact that the baby boomers were getting ready to hit retirement age, conveniently enough 2013 is the year the very first of the baby boomers have reached the statutory retirement age (67.)  Having held control of most of the lawmaking bodies in the country since around that time, there has been very little done that is going to ease the financial burden the Medicare system places on us as tax payers and members of an ever changing economy.
A little bit of a rundown of things I recall from “problems with government finance” here at MTSU supplemented with personal knowledge and a bit of internet searching about healthcare spending at the federal level.   The first thing I want to do is clear up a very popular misconception that is (at least seemingly) primarily responsible for the lack of change over the years.   When you get a paycheck and your taxes and social security is taken out, that is not going into a pot to pay healthcare and social security when you are old, it is paying for those things right now.  The feeling like they have been paying in and now it is the time to cash in, is one of the big reasons a lot of people do not want to make changes or eliminate social security and the Medicare programs they feel like it is owed to them.   I bring this up to establish the fact that if we are ever to change this pattern, something both McGee and I believe is necessary, a generation has to come into political power knowing that they have to choose to make it harder on themselves so that it can be more fair in the future instead of knowingly burdening our children with our care. 
I also want to bring up something I have made a seemingly obvious observation, something everyone seems to thing but no one says.  Many (if not most) people I see working in the healthcare field are not happy with their healthcare.  Insurance is a nightmare; Medicare, Medicaid, Tenncare (and similar programs), private insurance, it’s all the same. The same meaning extremely difficult to worth with and often times at least one person involved feels violated.  Before I get any farther I should mention that I have fallen in with the professors I have heard speak about Insurance, and that is that they are extremely inefficient from an economic standpoint, that inefficiency is a huge part of the problem inspiring me to choose this as my topic.  Economically all insurances work the same, lots of people put money into a big pot and when people need it they draw from the pot to help pay for their healthcare costs. A pretty simple concept, the only difference I know of in that fundamental concept is with federally funded aid the government is putting money into the pot instead of just the participants.
Now for those maddening inefficiencies, I’ll start with the biggest. Insurance companies are businesses.  They have to pay their workers, pay their executives, advertise, make themselves look good so they can survive in the corporate world, and so forth.  All of that eventually comes from your premiums, deductibles, and copays.   Without numbers to go on, my next guesses of wasteful inefficacies are Doctors prescribing haphazardly (I’ll elaborate on that further momentarily) and zero dollar copays.  Now, zero dollar copays sound nice right? Walk into the pharmacy smile and sign your name and they hand you medicine and you’re done.   Well, Economics has a little problem with that especially when combined with the next part.  When there is no cost at all, people pay less attention. They just grab whatever you hand them and take them (hopefully right, and hopefully they work,) this is not just a guess or economic theory, I see people do this on a daily basis.  Doctors make this problem far bigger by not always being very selective with the drugs they prescribe.  They fall prey to seductive drug reps and their baskets of coupons, free samples, and promises that the coupon will make it cheaper than the generic.
Spoiler Alert: 95% of the time, the generic is cheaper. Those coupons are just traps.
Or they prescribe a similar drug that is extremely expensive, when the cheaper drug would do just fine (more seduction by drug reps.) When you don’t have to pay the difference between the $200 pill and the $20 pill, people rarely care though.  Do this a few dozen times a day in each pharmacy all over the country and suddenly that $180 is a staggeringly huge difference.  Of course, vigilant and caring pharmacy workers try to mitigate this problem when they can, but they don’t always have the time or motivation.
The final problem I can point out before we can ponder about a solution is a problem in economics, if not THE primary problem. The problem(s) are called Free Riders.  Without refereeing either word in the title itself, the best way I can describe the free rider problem is through a scenario.
                Let’s say we have a happy little hippy/socialistic commune.  In this commune there is no currency, everyone works to produce food and when the food is harvested everyone partakes of it freely.  In a very small commune where everyone always know what each other is doing, it works pretty fine. But let’s say ours is just big enough that is a little default to keep exact track of everyone all the time.  Without fail, one or two people will slip under the radar and start partaking of food without helping produce it.  Those people are free riders.
Now back to our insurances.  In insurances we can have free riders play out in a few different ways.  One is by having people never put in a penny, and draw out (the most straightforward way of free riding) and one could classify many zero co-pay government funded insurances as all free riders.  The other (and less recognized way) is to have people not participate (and pay into) insurances until they need coverage, then suddenly try and get in.  
.  Both are problems that will stop us from creating an economically sound system (or at least getting as close as we can).
So let’s list the problems we have so far.
1.                   Upcoming tidal wave of retiring baby boomers.
2.                    Social/cultural resistance to change
3.                   Insurance companies are businesses
4.                   Inefficiencies
a.    Doctor’s prescribing issues
b.   Zero-copay waste
5.                   Free-riders
                Now for the fun part, where I start suggesting solutions and you all either agree or get increasingly uncomfortable/angry.   First of all, I am in favor of all or nothing solutions and hopefully some of them will make sense. 
The first problem I’ll address in problem 3, and to fix that we must make sure that our new program is either NOT a business at all or is heavily regulated. This can be accomplished by making it a nonprofit organization and gaining work from professionals like doctors, pharmacists, lawyers, accountants, and economists by making their time a tax deductible donation, something many of those people want.  This could also be achieved by establishing set pay rates for ALL employees, including all high ranking ones that are hard to change beyond planned cost of life increases.  Problem  3 down.
The next solution solves a few things at once, but would be really hard to sell to the public and companies. Once the program is established and running, abolish all other government and private insurance companies as well as mandate enrollment.  This is where the ethics and economics get a little twisted.  Competition is shut down (to get rid of the businesses) and enrollment is mandated (to eliminate the second kind of free riders,) although this would certainly enrage many it solves the economic problems created by their desire for fair healthcare. Now everyone is paying into and pulling from the same pot, which would allow the accountants and economists analyze the flow in and out and make policies based on it.  As well as make the government input into the pot far easier to see and keep track of.  Problem 5 down as well as hopefully 4a due to the inclusion of both doctors and pharmacists.
4b has elegantly simple economic solution, put a small co-pay on everything. A one to 3 dollar copay would likely help more than most people would initially think. Practically I know it works, when a Tenncare patient shows up and sees a $3 copay, everything comes to a screeching stop that usually ends with them having to leave and get money and often with them not getting it.
The only true solution to problem one however may be what McGee suggests in case 45 that retirement may be a thing of the past, when working ment hard labor and the elderly literally could not do any work. With many jobs that are far far less physically demanding many people can work to a far older age, and therefore still contribute to society and kick in at least a bit for their healthcare.  My proposed system may not take away this possible necessity completely, but reducing the inefficiencies we may be able to reduce the cost of healthcare to a level where many more people can afford to pay in for far longer. 

My proposals may not be perfect, but hey I'm just now getting my degree. If it were that easy to solve it surely would have by now.  But hopefully they would get us on the right tract, and with time and professional input we could perfect the system or at least not collapse economically trying to support a huge population of retirees.