1. "Natural" has popularly come to mean what, in the context of medicine?
2. The most unnatural aspect of vaccination is what?
3. What led to the creation of the EPA?
4. What kind of thinking makes no room for ambiguous identities, and what does it threaten?
5. What "troubling dualisms" characterize the vaccination debate?
6. What practice went on in China and India for hundreds of years, to combat smallpox?
7. What metaphor is implied by "inoculation"?
8. What disappointed Biss about the immuno-semiotics conference?
9. What game metaphor does Biss prefer, to describe our immune systems and viral pathogens?
10. What caused the fatal form of croup that has virtually disappeared in this country since the '30s?
11. What caused the spread of puerpal sepsis ("childbed fever")?
- Do you agree that the popular appeal of what is deemed more "natural" is a product of our "profound alienation from the natural world"?
- Are vaccines unnatural?
- Comment: "It is only when disease manifests as illness that we see it as unnatural." 42
- Should it bother us that Rachel Carson apparently was wrong about DDT being carcinogenic? 44
- With the apparent gutting of the EPA and other federal regulators now under way, will "the judicious use of chemicals" to fight insect-born diseases etc. still be possible? 45
- Are you comfortable with the idea of being a cyborg? 49
- Are you disproportionately afraid of sharks and oblivious to the dangers of bicycles? Does simply acknowledging such misperceptions help you to overcome them?
- Is immunity mostly a metaphor? Is it correctly characterized by metaphors of war? Do you agree with the perspective of alt-med practitioners on this point? 57
- Is parenting, with its attendant decisions impacting the future health of children, more "like time travel" than making health decisions for oneself? What do you make of the Star Trek example? Who in the present anti-vaxx scenario is "heroically return(ing) to the past to die"? 66
- Why do you think women healers historically were regarded as witches, albeit "good" ones? Are women fully welcome in the ranks of professional medicine today?
- Are there modern-day equivalents of "heroic" medicine (bleeding etc.)? Does it have a legitimate place in professional practice?
- Are we overly obsessed with "purity" and with avoiding toxicity? Are we never cleaner than our environment at large?
- Should human breast milk be commodified? If so, how should it be regulated?
- Your DQs
March 23, OI 77-109
1. What was ambiguous about the vampire metaphor, for Biss?
2. What struck Biss as both magical and mundane?
3. Smallpox is now no longer a disease, but a what?
4. Who were the Polio Pioneers? Where is polio still endemic, and why?
5. What are the profound differences between ethyl and methyl mercury?
6. How did Andrew Wakefield cause a "cascade of panic"?
7. Who accused WHO of collusion in 2009?
8. Why does Susan Sontag say public health is difficult to promote in our society?
9. Why does Arthur Caplan say the marketplace model of healthcare is dangerous?
10. When would Biss consider surgery a conservative option?
11. For what is there no credible evidence, "Dr. Bob" notwithstanding?
12. What's Biss's Dad's argument for preventive medicine?
- Why is it important to remember that "it's not your blood" that you must depend upon, when you need a transfusion?
- Is mutual bodily dependence ugly, beautiful, both, neither,... ?
- If our knowledge gives viral pathogens immortality, how can we effectively regulate them? 83
- What's the best way to combat "vaccine refusal" in the developing world? Is that different from how we should address it here? What would you say to Biss's Vietnamese friend? 87
- Are you worried about nefarious "invisible commercial influences" having an outsized influence on public health policy? Are you persuaded of the "power of the core public health ethos"? 95
- Is refusing immunity a legitimate form of civil disobedience, or a form of elitist self-indulgence?
- Is "shopping around for a doctor" (see cartoon below) ever appropriate?
- What do you think of Biss's critique of capitalism and what it is "really taking from us"? 97
- What do you think of the anesthesiologist's "disgusting" remarks? 102 Were they unethical, inappropriate, or excusable?
- What do you think of Biss's "Dad's "two sentence textbook"? 103
- Should a doctor be concerned with conditions in other docs' waiting rooms? How should they express such concern? 108
- I suggest we brainstorm several other DQs, in small groups during discussion time, and share them with the whole class before leaving today.
|Medical Ethics & Me (@medethicsandme)|
“Having raised humanity above the beastly level of survival struggles, we will now aim to upgrade humans into... fb.me/ETqAhy3e
Years after research contradicts common practices, patients continue to demand them and doctors continue to deliver. The result is an epidemic of unnecessary and unhelpful treatment.by David Epstein, ProPublica February 22, 2017
First, listen to the story with the happy ending: At 61, the executive was in excellent health. His blood pressure was a bit high, but everything else looked good, and he exercised regularly. Then he had a scare. He went for a brisk post-lunch walk on a cool winter day, and his chest began to hurt. Back inside his office, he sat down, and the pain disappeared as quickly as it had come.
That night, he thought more about it: middle-aged man, high blood pressure, stressful job, chest discomfort. The next day, he went to a local emergency department. Doctors determined that the man had not suffered a heart attack and that the electrical activity of his heart was completely normal. All signs suggested that the executive had stable angina — chest pain that occurs when the heart muscle is getting less blood-borne oxygen than it needs, often because an artery is partially blocked.
A cardiologist recommended that the man immediately have a coronary angiogram, in which a catheter is threaded into an artery to the heart and injects a dye that then shows up on special x-rays that look for blockages. If the test found a blockage, the cardiologist advised, the executive should get a stent, a metal tube that slips into the artery and forces it open.
While he was waiting in the emergency department, the executive took out his phone and searched “treatment of coronary artery disease.” He immediately found information from medical journals that said medications, like aspirin and blood-pressure-lowering drugs, should be the first line of treatment. The man was an unusually self-possessed patient, so he asked the cardiologist about what he had found. The cardiologist was dismissive and told the man to “do more research.” Unsatisfied, the man declined to have the angiogram and consulted his primary-care doctor.
The primary-care physician suggested a different kind of angiogram, one that did not require a catheter but instead used multiple x-rays to image arteries. That test revealed an artery that was partially blocked by plaque, and though the man’s heart was pumping blood normally, the test was incapable of determining whether the blockage was dangerous. Still, his primary-care doctor, like the cardiologist at the emergency room, suggested that the executive have an angiogram with a catheter, likely followed by a procedure to implant a stent. The man set up an appointment with the cardiologist he was referred to for the catheterization, but when he tried to contact that doctor directly ahead of time, he was told the doctor wouldn’t be available prior to the procedure. And so the executive sought yet another opinion. That’s when he found Dr. David L. Brown, a professor in the cardiovascular division of the Washington University School of Medicine in St. Louis. The executive told Brown that he’d felt pressured by the previous doctors and wanted more information. He was willing to try all manner of noninvasive treatments — from a strict diet to retiring from his stressful job — before having a stent implanted.
The executive had been very smart to seek more information, and now, by coming to Brown, he was very lucky, too. Brown is part of the RightCare Alliance, a collaboration between health-care professionals and community groups that seeks to counter a trend: increasing medical costs without increasing patient benefits. As Brown put it, RightCare is “bringing medicine back into balance, where everybody gets the treatment they need, and nobody gets the treatment they don’t need.” And the stent procedure was a classic example of the latter. In 2012, Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all. In general, Brown says, “nobody that’s not having a heart attack needs a stent.” (Brown added that stents may improve chest pain in some patients, albeit fleetingly.) Nonetheless, hundreds of thousands of stable patients receive stents annually, and one in 50 will suffer a serious complication or die as a result of the implantation procedure... (continues)
What the top U.S. health official should be saying on vaccines
Health and Human Services Secretary Tom Price. (Joshua Roberts/Reuters)
During a televised town hall last week, the nation’s top health official was asked whether all children should get immunized for measles and other vaccine-preventable diseases. In his response, Health and Human Services Secretary Tom Price parsed his words carefully. He said state governments (presumably rather than the federal government) “have the public health responsibility to determine whether or not immunizations are required for a community population.”
His response angered many doctors and public-health officials, who say the top U.S. health official failed to give full-throated support for immunizations that prevent disease and protect communities at a time when anti-vaccine sentiment is on the rise.
Paul Sax, an infectious disease specialist at Boston’s Brigham and Women’s Hospital, said Price might have been choosing his words carefully for political reasons. Price, he noted, belongs to the Association of American Physicians and Surgeons, an organization that opposes mandatory immunizations. And there’s Price’s boss, President Trump, who has publicly expressed discredited concerns about vaccine safety.
So Sax decided to write tongue-in-cheek answers for what Price should be saying. The post appeared in the HIV and ID Observations blog published by NEJM Journal Watch... (continues)
In recent years, scientists have moved beyond in vitro fertilization. They are starting to assemble stem cells that can organize themselves into embryolike structures.
Soon, experts predict, they will learn how to engineer these cells into new kinds of tissues and organs. Eventually, they may take on features of a mature human being.
In the report, John D. Aach and his colleagues explored the ethics of creating what they call “synthetic human entities with embryolike features” — Sheefs, for short. For now, the most advanced Sheefs are very simple assemblies of cells... (continues)
A hint of the future arrived in a study published this month by researchers at the University of Cambridge. They built microscopic scaffolding into which they injected a mixture of two types of embryonic stem cells from mice.
This triggered communication by the cells, and they organized themselves into the arrangement found in an early mouse embryo.
While these artificial embryos developed from embryonic stem cells, it may soon become possible to build them from reprogrammed adult human cells. No fertilization or ordinary embryonic development would be required to build a mouse Sheef.
“We need to address this now, while there’s still time,” Dr. Aach said.
Sophia Roosth, a Harvard historian of science who was not involved in the new paper, said she did not think ethicists would have to start from scratch to find rules for these strange new Sheefs. She was optimistic that experts could draw on the many regulations in place for other kinds of research — including cloning, human tissue studies, and even studies on animals.
“I don’t think the baby has to be thrown out with the bathwater,” she said.
Henry T. Greely of Stanford University was less optimistic. While it is important to have a discussion about Sheefs, he said, it may be hard to reach an agreement on limits as enforceable as the 14-day rule.
“Whether you could come to some consensus is really doubtful,” he said.
Even if ethicists do manage to agree on certain limits, Paul S. Knoepfler, a stem cell biologist at the University of California, Davis, wondered how easy it would be for scientists to know if they had crossed them.
Spotting a primitive streak is easy. Determining whether a collection of neurons connected to other tissues in a dish can feel pain is not.
“It gets pretty tricky out there,” Dr. Knoepfler said. “They’ve opened the door to a lot of tough questions.”
|douglas rushkoff (@rushkoff)|