A Discussion of "The Nature of Suffering and the Goals of Medicine"

This presentation focuses on The Nature of Suffering: and the Goals of Medicine, by Eric Cassell, M.D. In this work, Cassell puts forth an argument which seeks to reorient medicine away from what he considers a mechanistic reductionist view, towards one which sees patients as irreducible. Part of the issue is medicine has adopted an objective scientific approach that reduces patients with disease to diseased bodies, or puzzles to be solved. This method eschews the subjective nature of disease, the mental and personal aspects. Consequently, how subjective experience colors the embodiment of disease and suffering endured, can often be overlooked.
Cassell's argument mainly focuses on a philosophical critique of scientific medicine, not using anecdotal evidence of practitioner/patient relationships. I think this is important to note. If we were to take his words as a critique of the people performing medicine, we could easily object. It is towards a method that he aims his criticism, not doctors who face suffering and console patients and their families, daily.
To better understand Cassell, we must first understand what he is against. The mechanistic worldview has its roots in the philosophy of Rene Descartes. Descartes' main contributions were dualism, and a theory of nervous function. Dualism separated body from mind and mind from brain. Instead of consciousness being the result of the firing of a complex network of neurons, it was an immortal soul which rested in the pineal gland. The pineal gland was chosen as the seat of the soul due to it being one of the few regions of the brain which is non-hemispheric. Dualism is a top-down interactionist theory, which means the mind/soul can act on the body, but not vice versa. To tie this in with his theory of nervous function, when we react reflexively to our hand coming into contact with fire it is due to “animal spirits” descending from the pineal gland through the nerves. These animal spirits are what cause our hand to recoil, hence top-down interaction. We know now it is quite the opposite and much more complex. To Descartes, the body was like a complex machine piloted by the soul from the pineal gland via animal spirits. Descartes view is biased towards the soul and diminishes the body as an object. His ideas were influential and shaped world views for hundreds of years.
This is the root of the scientific medicine Cassell is reacting against. As Descartes views the mind/body relationship as dualistic and top-down interactionist, scientific medicine also sees the patient as a separate mind and body, with little regard to the mind. The diseased body, or the damaged machine, is where scientific medicine focuses its efforts and sees any adjustment of the body as having little effect on the mind. Therefore, scientific medicine is reductionist, because its view of the patient is of a collection of parts instead of a whole.
Cassell seeks to reorient scientific medicine by intertwining his views on the nature suffering, the philosophical concept of personhood, and the paradox of treatment. Suffering is an experience separate from pain and is felt despite it. It is something influenced by many variables, all of which form what Cassell terms, “the background of illness.” These variables are essentially what makes up the patient as a person, things such as: culture and society, family, the past, private life, associations, relationships, politics, perceptions of the future, and the transcendent being. The paradox of treatment, where treatments of disease (e.g. chemotherapy) tend to cause suffering, is intensified by the background of illness. Certain treatments have side effects, such as: hair loss, fatigue, weight change, mood imbalance, changes in libido and sexual function. These side effects of treatment can interact with the background of illness, creating a cocktail of suffering. This suffering is due to changes in the patient’s relationships with partners, their place in society, their view of the future, and their own identities. Cassell illuminates these complexities which exist alongside diseases medicine seeks to cure. Is it the goal of medicine to cure disease? According to Cassell, the obligation of physicians is to relieve human suffering. It is the goal of medicine then to relieve suffering, and curing disease is contributory, not the end we seek.

Quiz Questions

1. What does this presentation focus on?
2. Who is Rene Descartes?
3. Cassell's argument seeks to reorient medicine away from....?
4. What does scientific medicine eschew? Objectivity or subjectivity?
5. What is the paradox of treatment?
6. According to Cassell, what is the obligation of physicians?

Discussion Questions
1. What do you guys think? Especially any pre-med students. In your courses, or how we discuss the practice of medicine, do you feel consideration is made to how a patient’s mental state and experience can influence their illness and suffering?
2. The simplistic critique is always, “doctors have bad bedside manners.” Could this be less about personality and more about how one may view the goal of medicine? (Do they see the goal as the eradication of a disease, of suffering, both or neither? Obviously, I believe doctors are overworked! But let's consider this philosophically.)
3. Just for fun….do you think the study of literature, history, and art, has a place in the broad study of medicine? If so, how so?

Synthetic Brains

https://www.theguardian.com/science/2019/mar/18/scientists-grow-mini-brain-on-the-move-that-can-contract-muscle
https://bigthink.com/surprising-science/brain-science?rebelltitem=4#rebelltitem4

In recent years, genetic scientists have begun growing brains. Not creating computers or processors that can think for their own, not taking cells from an existing brain and having them operate independently, not even transplanting a functioning brain into a new organism for potential growth. Scientists are actually growing brains from scratch. Now, this wouldn't be nearly as unsettling if the brains were just that, a brain, with no connection to the outside world. However, whether it be a good or a bad thing, Cambridge scientists have created a brain, which they have called their "mini-brain on the move", which both can and does react to its surroundings. When placed near a removed mouse spinal cord in its environment, the mini brain was shown to grow tendrils reaching towards the spinal cord without any previous "encouragement," showing that it is some sort of instinct, or natural response of the brain to expand. Not only that, once the brain had connected to the spinal cord, it was able to send signals to the muscle tissue attached to the spinal cord, and cause it to flex, in the same way our brains move our muscles on our body.

To me, this is chilling. The fact that scientists are able to synthesize what appears to be a new life in a Petri dish out of nothing but a few stem cells that has the capacity to both react and adapt to its environment seems like something out of a science fiction movie. If we are able to create brains that can interlink with their surrounding nervous systems, what implications could this have towards humans if we manage to grow a human brain? Could scientists grow a brain with the capacity of a humans', place it into a cadaver, and expect a similar response? While this may be a bit of a stretch, something similar already seems plausible from the efficacy of the brain next to the mouse spinal cord.

But it doesn't stop there. Scientists at the D'Or Institute for Research and Education grew a brain which, after a few weeks, started developing retinal cells. These were identified to be the foundations of the brain growing eyes. So, now we know that not only are these synthetic brains able to develop on their own, they are able to develop intelligently, and optimize their understanding of the world around them. Only our imaginations can limit what the potential of these brains may reach. If they can develop retinal cells and start to be able to see, how far away are they from starting to grow their own muscles to move around? How far are they from being able to have their own thoughts, as opposed to simply reacting to their environment? How far are these brains away from being conscious?

Unfortunately, that is a question that scientists are confident about the answer to, but also have no solid guarantee. The researchers who are creating these "brains in a jar" are extremely sure that they are nowhere close to developing consciousness. However, one can't help but be skeptical as to the certainty of this assumption. There is absolutely no way for scientists to gauge the points where consciousness is achieved, whether or not it is an instantaneous "spark" of profound self-awareness, or whether or not the brain is conscious the whole time, and simply cannot yet act upon its own intentions. There is no benchmark for where simple scientific toying ends, and the creating of a new form of consciousness begins. And the brains that are being grown are not even at their highest possible complexity! Scientists are still creating environments and structures in order to allow these synthetic brains to grow more and more complex and sophisticated. With this approach to the dangerous study of brain synthesis, it seems that we are approaching the day of harvesting consciousness at a breakneck speed. In my opinion, a line needs to be drawn in the sand before we come to this day.

This also bears the question, what kind of medical implications or applications would experiments like these bring about? Is this research being used to contribute to the field of medicine, or is it just a matter of scientists trying to play God? From what I can tell, there doesn't seem to be any immediate benefit to the creation of these synthetic brain and spine amalgams other than to sate our thirst of curiosity. If there is any medical benefit from doing such research, then I can fully support the pursuit. If these are simply being carried out for our pleasure and interest, however, I think it would be wise to stop now before we create something that we don't know how to control.

Legislators Are Not Stupid People. So What’s Behind Their Stupid Behavior?

Following the Koch playbook, Tennessee keeps finding new ways to undermine the welfare of its citizens.

NASHVILLE — The 111th General Assembly of Tennessee convened on Jan. 8, and it will disperse on April 26, not a moment too soon. Already, its Republican supermajority has introduced bills that would further weaken lax gun laws, increase campaign-donation limits and undermine a progressive Nashville law passed by public referendum, among other assaults on democracy and good sense. Tennesseans should get down on their knees and thank God for the citizen-legislator model of government, because there’s no telling how much damage these people could do if they met all year.

Fortunately, much of what happens in the General Assembly is pure political posturing. So far this year, Tennessee Republicans have introduced bills to amend the state constitution (they want it to insist that “liberties do not come from government but from Almighty God”), prohibit state officials from recognizing marriages between people of the same gender, deny birth certificates to babies born to undocumented parents and, most controversially, outlaw abortion after a fetal heartbeat can be detected. Heart cells begin beating so early in gestation that many women don’t yet know they’re pregnant.

None of these proposed laws would accomplish anything at all. God is already invoked three times in the constitution of Tennessee, and the United States Constitution has already established birthright citizenship for babies born in this country. The Supreme Court has made same-sex marriage the law of the land, and the “heartbeat bill” would run afoul of Roe v. Wade, the landmark U.S. Supreme Court ruling that protects a woman’s right to an abortion. The American Civil Liberties Union of Tennessee and Planned Parenthood of Tennessee and Northern Mississippi have already announced that they will challenge the law if it’s passed, and they will win in court.

Bills like this are red meat to the constituencies that elected the Republican supermajority in the first place. But this year, resistance to their efforts has come from surprising places: business and the religious right.

Last May the asset-management firm AllianceBernstein announced that it would be moving its headquarters to Nashville — and creating more than 1,000 jobs here — in part because of $17.5 million in financial incentives provided by the state. Earlier this month, the company’s chief executive, Jim Gingrich, joined with local LGBTQ advocates in assailing several bills designed to suppress gay rights in Tennessee, pointing out that such bills in other states have proven to be “anti-growth, anti-job and against the interests of the citizens of those states.”

The fetal-heartbeat bill faces similar opposition from within a traditional Republican camp. All three of Tennessee’s Catholic bishops oppose the bill, and so does Tennessee Right to Life, the primary anti-abortion group in the state. That’s because a losing court battle would force the state to pay costly legal fees — its own and its opponents’ — as well as create a legal precedent that would dog future anti-abortion efforts. Nevertheless, the Tennessee House of Representatives passed the bill on a 65-21 vote.

It now goes to the State Senate for consideration.

It would be easy to dismiss — even laugh at — politicians so resolutely determined to shoot themselves in the foot. But from time to time they do manage to pass laws, and some of those laws cause immense pain to innocent people. In 2015, members of the Republican supermajority rejected a plan by their own Republican governor, Bill Haslam, to expand TennCare, the state’s Medicaid program and provide health insurance to hundreds of thousands of low-income Tennesseans not covered by the Affordable Care Act. Governor Haslam’s plan would have cost the state no additional funds, and it was supported by an overwhelming majority of Tennesseans. Adding insult to injury, the failure to expand Medicaid has caused the widespread closure of hospitals in this state — a dozen so far, with many others teetering on the verge of insolvency — and there have been many other predictable ramifications of leaving so many people without health insurance.

In 2018, the state legislature passed a law that required “able-bodied” Tennesseans who do qualify for TennCare to hold a job or go to school if they wanted to keep their health insurance. The state is currently seeking permission from the federal government to implement this requirement and will presumably get it. When that happens, 68,000 more Tennesseans will lose their health insurance — because they lack transportation, for example, or don’t have access to affordable or reliable child care. The requirements will also cost the state an additional $19 million in administrative costs, even taking into account the money saved by reducing TennCare rolls. Even if Republican lawmakers aren’t concerned about their uninsured fellow citizens, you’d think a figure like that might catch their attention.

Every morning I read Joel Ebert’s heroic statehouse reporting for The Tennessean, Nashville’s daily newspaper, and I wonder what in the world is going on. These are not stupid people. What possible explanation lies behind such stupid behavior?

Lately, though, I’ve been remembering the historian Nancy MacLean’s brilliant book, “Democracy in Chains: The Deep History of the Radical Right’s Stealth Plan for America.” The book is a history of the far right’s decades-long effort to take over statehouse governments and enact an extreme libertarian agenda at the local level and, by accrual, disrupt the normal workings of democracy at every level. The irrational behavior of the Tennessee General Assembly is completely coherent when viewed through the book’s lens.

According to Dr. MacLean, the Koch network’s goal — and the goal of all legislators in thrall to the Kochs’ PACs — is to weaken unions, suppress voter turnout, privatize public education, undercut climate science, roll back existing environmental protections, dismantle the social safety net and, of course, stack the courts with sympathetic judges. To enact that unpopular agenda, they’ve had to make common cause with the religious right.

Indeed, virtually every bill introduced in Tennessee’s General Assembly this legislative session is designed to outright the religious right (by, for example, introducing an anti-abortion bill that can’t possibly survive legal scrutiny), diminish the legislative power of blue cities, and, above all, demonize anyone who can be painted as a needy “other.”

We tend to focus our shock and outrage on the manifold travesties unfolding on the national stage, but it’s a mistake to tune out what’s happening in statehouses around the country, for Tennessee is far from alone in following the Koch playbook. Hours after Tennessee legislators passed the fetal-heartbeat bill, Georgia passed a nearly identical one, and in recent years similar bills have passed in Arkansas, Florida, Iowa, Kentucky, Minnesota, Mississippi, Missouri, North Dakota and Ohio. Fifteen other states have added work requirements of some kind for Medicaid. Texas has already tried, and failed, to prevent the children born to undocumented parents from receiving birth certificates. The list goes on and on: the death of compassionate democracy by a thousand paper cuts.

Dr. MacLean notes that even Justice Clarence Thomas, one of the most conservative members of the Supreme Court, has expressed profound concern about the current state of the body politic: “We are going to have to recognize that we are destroying our institutions,” he said in a conversation she quotes in “Democracy in Chains.” He was talking to the Heritage Foundation, a conservative think tank.

For all its often-empty swagger, the Tennessee General Assembly has made one thing very clear: If Americans don’t start paying closer attention to what’s happening in statehouses across the country, the republic may never recover.

Margaret Renkl

Quizzes March 19, 21

Add your questions etc.

Mar 19-Beyond 23-27

1. In this touted Age of Genomics, what frequently follows the hopeful hype about gene therapy?

2. Steve Jones says we know what of genetics?

3. What was Francis Collins' prediction in 2000? In 2014?

4. What's the best way to engineer a tall person, and what does that tell us about the effects of "Many Assorted Genes..."?

5. "Anonymous" tissue samples can be what?

6. What is Jessica Cussins' practical objection to the results of DTC genetic tests?

7. What more than doubled in illustration of the "Angelina Jolie effect"?

8. There aren't enough what to support population-wide screening for the BRCA genes?

9. The UC-Berkeley DNA project was intended to introduce students to what?

10. How should leading geneticists have responded to loose talk in the early '90s (and still) about "the gay gene," "the violence gene," etc.?

DQ

• Who's responsible for over-hyping the promise of gene therapy?
• Why is the history of genomics so full of unfulfilled promise?
• If short people are discriminated against, is the solution to engineer tall people? Or to oppose discrimination more aggressively?
• Do you agree that we should divert billions from genomic research to behavioral modification? 249
• Why do patients who support genomic research nonetheless "want to be informed..."? 251
• Is there any reason in principle why 23andMe's algorithm could not be corrected to detect and distinguish gene mutations that are and are not life-threatening? 253
• Is there anything ethically wrong with women electing for prophylactic mastectomies?
• Do the risks of universal screening for the BRCA genes outweigh the benefits? 
• If there were enough genetic counselors to support population-wide screening, would you support it?
• Should patients be informed of mutations that are not found to correlate with increased cancer risk? 257
• Is it in fact "common knowledge" that there isn't a gene for homosexuality, etc.?
• 
  

Health news... Weekly health quiz... WHQ 3/8... WHQ 3/3...  Treating Alzheimer's... Her son died. And then anti-vaxers attacked her

Mar 21-Beyond 28-31

1. The greatest advances in health and longevity should go to what?

2. Why was BiDil removed from the market?

3. What broad consensus now obtains regarding health differences between and within groups?

4. Funding in 2014 was 50% greater for research areas including the word gene (etc.) than for those including the word _____.

5. Name an "unthinkable" medical experiment to which incarcerated individuals have been subjected.

6. Creating ethical standards for medical research is the flip-side of what "coin"?

7. Most viewers of The Constant Gardener would probably conclude what, mistakenly, about its fictional drug company?

8. Apart from being extraordinarily lucrative for the local doctors who procure test subjects in developing countries, what's another important reason why so much human research is conducted in Africa and other poor regions outside the U.S.?

9. Research in Nigeria for Pfizer was compromised by an apparently fraudulent claim involving a nonexistent what?

10. What two questions should be prerequisite to conducting research in the third world? What should precede human research anywhere in the world?

DQ

• Do you have a duty to be your best self? To whom?
• Is aging a "scourge worse that smallpox"? 265
• How can emergent biomedicine be suitably tailored to public (not just personal & profitable) health?
• COMMENT: "Health is determined by far more than health care." 269
• What forms of preventive medicine/health care do you think would have the greatest constructive impact on health in the U.S.?
• Is there any rationale for ever using human "guinea pigs" for research?
• Are adequate safeguards in place to prevent future research abuses targeting prison populations?
• What do you think of South Carolina's kidney proposal 278
• What's wrong with offering incentives to imprisoned women to donate their eggs?
• Have you read and/or seen The Constant Gardener? What's your review? (If you haven't, are you mad at Marcia Angell for her spoilers)?
• What do you think of CG's Hollywood ending (in the film)?
• 
  

Statistical Ethics and the Outlook for Doctors

We have talked in class about the affect of journals and the manipulation of data. Awareness of this can change the view of the public and the scientific community at large. I was sitting in Biometry, statistics for biology, when he played the video bellow.

I was not surprised but it felt like something to be proud of. There are people in the world who know that there are problems and ways to fix it. It also helps that Dr. Goldacre is an entertaining presenter. I also learned about a different test that can tell us if data is missing from the results based on how much error is.

Above is a type of plot called a funnel plot, used to show how much information is being shown based on error and precision. Ideally, according to Dr.Goldacre's presentation transcript and a cross reference of what looks like an educational website and Science Direct's review of the topic, the shape of the pyramid can show bias and missing studies. Dr. Goldacre states that the smaller the sample size, the more error and variety in the data. In simple terms, the bottom should be wide and even, ideally. The larger populations should be grouped in one area to show similar results, also visualized as a point of the pyramid. If the pyramid is lopsided or multi modal(two pointed, two clusters), bias can be suspected. The American Statistics Association has a set of ethical guidelines for the use and presentation of data, available on their website. Statistics are everywhere, we use them to determine markets, play games, tell the weather, and even predict outbreaks of disease in our own field. To ignore the potential facts because of potential bias is foolish, teaching analysis and critical thinking to our doctors and the presenters is more proactive.

Embryo Ethics: The Stem Cell Debate

Stem cells are cells in the human body that have the potential to develop into any of the many different cells found in the human body. There are two types of stem cells: embryonic and adult. Here we will focus on the embryonic stem cells. Stem cells were first introduced as a possible area of research by the idea of them possibly being able to cure diseases, such as diabetes, Parkinson's, and ALS. In 2006, Congress had voted to approve stem cell research, only to be vetoed by George W. Bush since he thought it was unethical due to it destroying the blastocyst, an unimplanted embryo at the sixth to the eighth day of development and that the federal government should not support the "taking of innocent human life".  Sandal states in his book that there are 3 main questions that this research proposes: should embryo stem cell research be permitted, should it be funded by the government, and should it matter if stem cells are taken from already existing embryos left over from fertility treatments or from cloned embryos. He describes the first question as the most intractable. The main argument against this research is that it destroys a human embryo, which some see as equivalent to killing a child. This is where most of the debates over stem cell research are derived from today. The second question that arises from the stem cell debate will be determined by the answers to the first. If the answer to the first question is a complete opposition to stem cell research, there would be no funding from the government. However, if stem cell research is ever deemed ethical to some degree and is permitted, the debate as to whether the government should fund it would be brought into question. Some may believe that the government should get involved as this research could be potentially life-saving and improve the quality of life for its citizens. Others may think that government involvement in funding is not necessary and would cross the line of where the government's influence should stop. Sandal then goes into whether there is a moral difference in the use of "excess" embryos or cloned ones. As of right now, there is no federal law that prohibits cloning of an embryo, mostly due to most officials and public opinion oppose it. Many oppose cloning because they believe a cloned embryo is still a person, bringing us back to the main argument of this research: that destroying an embryo is essentially killing a person. However, many argue for the idea of using "excess" embryos from fertility clinics in research because if they are just going to be discarded, we might as well use them for potentially life-saving research. This position was defended by the Senate, the Senate's only physician, and by the then Massachusetts governor Mitt Romney. However, from this position, another argument arises. Whether or not fertility clinics would have two types of donations, one for IVF, which too many fertilized embryos are already being made, and donations specifically for stem cell research.

Questions:

1) What are embryonic stem cells and at what stage of fertilization are they obtained from?
2) Which president vetoed the bill for stem cell research that was voted for and approved by Congress?
3) What is one of the three questions that arise from stem cell research, according to Sandal?
4) Why is there no federal law prohibiting cloning of an embryo as of right now?
5) What position was defended by the Senate, the Senate's physician, and Mitt Romney regarding stem cell research?

Is 'Egg Freezing' Better than IVF?

Egg freezing know as oocyte cryopreservation has become more popular over the years. Why are women freezing their eggs? There are various reason why a woman would choose to freeze her eggs, some for work or school related issue others for health concerns. Freezing eggs to preserve fertility has become a popular treatment, due to its ability to work without the need for sperm unlike the IVF technology. Still, this process still remains an expensive one. This process takes typically around 4 to 6 weeks of preparation referred to as a cycle. A cycle can be about $10,000 for freezing and storing. The average cost to freeze and store your eggs for 15 years is approximately around $32,000-53,000. For some this amount might not be worth it considering the success rates of pregnancy in this treatment. Each egg, or oocyte, has the estimated survival rate of 4-12 percent. The percentage would differ per woman based on age. It is important to consider that the most important factors to keep in mind is your success rate lies on age of freezing and how many eggs you froze.

This could be a reason why the egg freezing market has been targeting a younger audience, women in their mid-twenties. By age 35 female fertility has dropped to around 50 percent. However, with a high price (and considering a significant probability of failure) how many women can actually afford to pay for this treatment?

While women with health concerns might receive help from their insurances, others might benefits from working with a company that provides it as one of their health benefits. In fact, some Fortune 100 companies, like Apple, Netflix, etc. have offered this among their benefits and critics have questioned the impact this could have to the workplace demographic. Some say this could possibly allow for discrimination against the women who choose to not use this option. Many think the employers would ultimately benefits due to favoring women who will most likely choose to work and secure financial stability before taking on motherhood.

Another option of treatment for some people who are having trouble conceiving, would be IVF or in-vitro fertilization. The process of IVF requires egg retrieval and sperm sample to be used in insemination. After this, when the egg becomes embryos it is inserted inside the woman again. One thing that is different about this, is that if both the male and the women are infertile, they need can choose to have donors for both the sperm and egg. This option is sometimes used by couples where the man might be the one with low fertility rate. This too is also an expensive option nonetheless and oftentimes is not covered by insurance plans. This treatment takes about a month and can cost around $12,000-17,000 for a single cycle. Again the success rate for this is dependent on age and can range from 40% for women under 35 and 33-36% for women between 35-37. 

Both of these treatments have shown to have reshaped our normal timeline of parenthood. I see how egg freezing has become a more popular option amongst young women and I think it’s a less controversial procedure, being less ethically intrusive.

Works cited:
https://americanpregnancy.org/infertility/in-vitro-fertilization/
https://www.advancedfertility.com/ivf.htm
http://obgyn.ucla.edu/egg-freezing
https://www.nbcnews.com/health/health-news/expensive-lottery-ticket-freezing-eggs-offers-women-hope-not-everyone-n975921
https://news.bloomberglaw.com/health-law-and-business/insight-employer-subsidized-egg-freezing-benefitswho-really-pays

ER-$!

	Fresh Air (@nprfreshair)
3/13/19, 10:00 AM How can an ER visit where you only get a Band-Aid cost $629? TODAY: Why emergency room visits cost so much -- even if you have health insurance. Vox health policy reporter ⁦‪@sarahkliff‬⁩ investigates ER bills and the mysterious fees behind them.

Nano-bot can probe inside human cells- University of Toronto Faculty of Applied Science & Engineering

University of Toronto Engineering researchers have built a set of magnetic 'tweezers' that can position a nano-scale bead inside a human cell in three dimensions with unprecedented precision. The nano-bot has already been used to study the properties of cancer cells, and could point the way toward enhanced diagnosis and treatment.

The U of T Engineering researchers' system uses six magnetic coils (pictured) to control the position of a microscopic iron bead within the device. The bead is small enough to enter human cells and can be positioned with unprecedented accuracy.

Credit: Tyler Irving / U of T Engineering News

Professor Yu Sun and his team have been building robots that can manipulate individual cells for two decades. Their creations have the ability to manipulate and measure single cells -- useful in procedures such as in vitro fertilization and personalized medicine. Their latest study, published today in Science Robotics, takes the technology one step further.

"So far, our robot has been exploring outside a building, touching the brick wall, and trying to figure out what's going on inside," says Sun. "We wanted to deploy a robot in the building and probe all the rooms and structures."

The team has created robotic systems that can manipulate sub-cellular structures inside electron microscopes, but that requires freeze-drying the cells and cutting them into tiny slices. To probe live cells, other teams have used techniques such as lasers or acoustics.

"Optical tweezers -- using lasers to probe cells -- is a popular approach," says Xian Wang, the PhD candidate who conducted the research. The technology was honoured with 2018 Nobel Prize in Physics, but Wang says the force that it can generate is not large enough for mechanical manipulation and measurement he wanted to do.

"You can try to increase the power to generate higher force, but you run the risk of damaging the sub-cellular components you're trying to measure," says Wang.

The system Wang designed uses six magnetic coils placed in different planes around a microscope coverslip seeded with live cancer cells. A magnetic iron bead about 700 nanometres in diameter -- about 100 times smaller than the thickness of a human hair -- is placed on the coverslip, where the cancer cells easily take it up inside their membranes.

Once the bead is inside, Wang controls its position using real-time feedback from confocal microscopy imaging. He uses a computer-controlled algorithm to vary the electrical current through each of the coils, shaping the magnetic field in three dimensions and coaxing the bead into any desired position within the cell.

"We can control the position to within a couple of hundred nanometers down the Brownian motion limit," says Wang. "We can exert forces an order of magnitude higher than would be possible with lasers."

In collaboration with Dr. Helen McNeil and Yonit Tsatskis at Mount Sinai Hospital and Dr. Sevan Hopyan at The Hospital for Sick Children (SickKids), the team used their robotic system to study early-stage and later-stage bladder cancer cells.

Previous studies on cell nuclei required their extraction of from cells. Wang and Sun measured cell nuclei in intact cells without the need to break apart the cell membrane or cytoskeleton. They were able to show that the nucleus is not equally stiff in all directions.

"It's a bit like a football in shape -- mechanically, it's stiffer along one axis than the other," says Sun. "We wouldn't have known that without this new technique."

They were also able to measure exactly how much stiffer the nucleus got when prodded repeatedly, and determine which cell protein or proteins may play a role in controlling this response. This knowledge could point the way toward new methods of diagnosing cancer.

"We know that in the later-stage cells, the stiffening response is not as strong," says Wang. "In situations where early-stage cancer cells and later-stage cells don't look very different morphologically, this provides another way of telling them apart."

According to Sun, the research could go even further.

"You could imagine bringing in whole swarms of these nano-bots, and using them to either starve a tumour by blocking the blood vessels into the tumor, or destroy it directly via mechanical ablation," says Sun. "This would offer a way to treat cancers that are resistant to chemotherapy, radiotherapy and immunotherapy."

These applications are still a long way from clinical deployment, but Sun and his team are excited about this research direction. They are already in process of early animal experiments with Dr. Xi Huang in SickKids.

"It's not quite Fantastic Voyage yet," he says, referring to the 1966 science fiction film. "But we have achieved unprecedented accuracy in position and force control. That's a big part of what we need to get there, so stay tuned!"

Nano-Bot Article- Science Daily




DQ:

What ethical issues can arise from this emerging technology?

The Lesson of Impermanence

A chance encounter with a sand painting helped me learn how to doctor patients I knew I would lose.

As a palliative care doctor, I spend much of my time face-to-face with pain and suffering, debilitating disease and death. When I began my training, I thought I was comfortable with the idea of mortality, and with the notion that fighting death at all costs wasn’t the sole purpose of medicine. But I hadn’t expected that the type of medicine I’d chosen to practice would require a strength and perspective that medical training hadn’t offered.

It was a chance encounter with a sand painting that helped me learn how to doctor patients I knew I would lose.

At the time, I was in the middle of my yearlong fellowship in hospice and palliative medicine, seeing patients at a county hospital in San Jose. I’d immersed myself in learning how to treat patients living with serious illnesses: end-stage heart failure, widespread cancer and devastating strokes. I’d learned how to help families anticipate what dying looks like. It had become second nature to talk openly with patients about the severity of their diseases, and to ask them how we might work together to maximize joy, meaning and comfort in their waning lives.

I hoped that projecting an acceptance of death and comfort with it might soothe my patients and their families. But I had grown progressively more anxious, and occasionally despondent. I didn’t understand why death had come for a 35-year-old mother of three with a rare and aggressive cancer, or why a marathon runner was dying after a sudden heart attack when he’d been a marathon runner...

The (Potential) Miracle of the London Patient

I might be exaggerating but I am truly excited for this topic. I was watching one of my sources for news, Philip Defranco a journalist with a very prepared team. His show brought to my attention the use of bone marrow transplants and how they can help HIV and AIDS patients. You see, bone marrow makes blood cells and when your body is attacking itself and is unable to fight off infections from other conditions, a side effect of HIV, a transplant from another person can assist your creation of new cells. Researchers have found that some people have cells that are resistant to this effect and when their marrow is transplanted, it can lead to potential resistance in patients. This allowed the London patient to go into a remission or at the very least, stop the need for antiviral drugs. This is no reason to get out and party however as research is still ongoing, transplants do not last forever, and above all else; this really only helps individuals prevent the spread. This is not even considering that bone marrow is a donated tissue, requiring testing, and the hope that the resistance is there. AIDS and HIV do not get mentioned often in the news because of the antiviral drugs that can offer protection for those suffering. The last thing I heard was California's move to lower the penalty for knowingly expose someone to the condition, a move that blew my mind that anyone would do that. Any insight from our future doctors?

Night Shift Health and Compensation

Sleep is an important component of maintaining the bodies necessary processes. A list of just a few broad benefits of obtaining adequate, regular sleep are better physical, mental, and emotional health. Not receiving adequate, regular sleep also has risk such as fatigue, clouded thinking and judgement, and falling asleep during activities that could lead to self-harm or the harm of another.

We live in a society that “doesn’t sleep” in that while part of society is asleep after 10:00pm, a large amount of individuals have just begun their day of work. Often capitalism requires production to continue 24-hours a day, seven days a week and unfortunately, sickness and injury don’t halt after what would be considered “normal sleeping hours” begin. Various security companies require 24-hour surveillance for the things that bump in the night and I am sure there are many other professions that practice the same concept that I have not mentioned.

Night-shift workers often go against nature in their sleep patterns. They are active when the sun is going down and climb in to bed as the sun is rising. Often times, they have trouble sleeping due to the normal buzz of daily activities and due to resistance from their bodies that know this schedule does not meet the bodies intended use. Night-shift workers may only sleep for a couple hours at a time and also trade-off sleep in order to spend time with their loved ones and children who carry a normal schedule.

Many new studies are being done to determine what effects working nights has on the human body. Some studies found poorer health outcomes and shorter lifespans. Also, those working nights report feeling more tired throughout the week and having trouble going back and forth between the night-shift work schedule and the day schedule, when they are off of from work. Some companies offer shift-differentials to encourage individuals to feel night-shift positions, but is it worth the health and social tradeoffs? 

DQ:

1. If society requires that someone be up in the middle of the night in order to continue their production, care for the sick or protect their prized goods, what should be the reward for their abnormal schedules, potentially negative health outcomes and time spent away from their families? 

2. Is offering a higher pay enough? 

3. Is requiring that companies cut off production hours a solution? 

4. What about all of the jobs that would be lost? 

5. What about hospitals? 

6. What can be done to help night-shift employees remain physically and emotionally healthy to provide the best health outcomes for the patients they care for?

Benefits of Regular Sleep
Role of Sleep

Shift Work Syndrome

The Real Horror of the Anti-Vaxxers, & etc.

This isn’t just a public health crisis. It’s a public sanity one.

How many studies do you have to throw at the vaccine hysterics before they quit? How much of a scientific consensus, how many unimpeachable experts and how exquisitely rational an argument must you present?

That’s a trick question, of course. There’s no magic number. There’s no number, period. And that’s because the anti-vaccine crowd (or anti-vaxxers) aren’t trafficking in anything as concrete, mundane and quaint as facts. They’re not really engaged in a debate about medicine. They’re immersed in a world of conspiracies, in the dark shadows where no data can be trusted, nothing is what it seems and those who buy the party line are pitiable sheep.

And, boy, are they living at the right time, when so much information and misinformation swirl by so quickly that it’s easy to confuse the two and even easier to grab hold and convince yourself of whatever it is you prefer to believe. With Google searches, you find the ostensible proof you seek. On social media, you bask in all the affirmation you could possibly want.

The parents who are worried or sure about grave risks from vaccines reflect a broader horror that has flickered or flared in everything from the birther movement to “Pizzagate,” that nonsense about children as Democratic sex slaves in the imagined basement of a Washington pizza joint. Their recklessness and the attendant re-emergence of measles aren’t just a public health crisis. They’re a public sanity one, emblematic of too many people’s willful disregard of evidence, proud suspicion of expertise and estrangement from reason...

(Frank Bruni, continues)

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Have anti-vaxxer friends? Share this educational video. pic.twitter.com/GQQTRO6E5m

— NYT Opinion (@nytopinion) March 11, 2019

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Doctor on Video Screen Told a Man He Was Near Death, Leaving Relatives Aghast https://nyti.ms/2VMsXAT

An Unvaccinated Boy Got Tetanus. His Oregon Hospital Stay: 57 Days and $800,000. https://nyti.ms/2EY6jjb