» Health Care Where the World Finds Bioethics Tue, 22 Apr 2014 22:10:42 +0000 en-US hourly 1 Cloning advance using stem cells from human adult reopens ethical questions Tue, 22 Apr 2014 16:51:04 +0000 0 HealthCare & Immigration: A Summary to Accompany BioethxChat Twitter Event (4/21/14) Mon, 21 Apr 2014 22:30:33 +0000 0 Easter, Fertility, Surrogacy Mon, 21 Apr 2014 15:28:43 +0000 Read More »]]> 0 People in the US Are Footing the Bill for Switzerland’s Medical Care Mon, 21 Apr 2014 14:59:55 +0000 Continue reading ]]> 0 Being Wrong is Unacceptable: The Continued Saga of Justina Pelletier Mon, 21 Apr 2014 13:47:09 +0000 ]]> 0 To boldly go? Experts issue ethics guidelines for health standards on NASA’s next generation of risky missions Mon, 21 Apr 2014 13:14:44 +0000 0 Doing Everything Possible: The Best or Worst Thing about American Medicine (VIDEO) Mon, 21 Apr 2014 09:00:00 +0000 0 Astellas to pay $7.3M in drug-marketing settlement Sun, 20 Apr 2014 23:07:22 +0000 0 Italian court overturns divisive ban on donor eggs, sperm Sun, 20 Apr 2014 23:05:09 +0000 0 Pint-Sized Pot and Hospice Hallucinations: The Role of Illicit Drugs in Medicine Sun, 20 Apr 2014 17:15:05 +0000 ]]> 0 DHHS Will Pay You $75 to Register Your Advance Directive Sun, 20 Apr 2014 12:00:00 +0000 0 The Resurrection Body Sun, 20 Apr 2014 06:00:59 +0000 Read More »]]> 0 10 Common Questions (and their Answers) on Medical Futility Sun, 20 Apr 2014 02:03:00 +0000 0 The Rise of Economism in the US: The Business Side Sun, 20 Apr 2014 00:48:00 +0000
I recently posted about Daniel Stedman Jones’s book, Masters of the Universe, a history of the rise of economism (which he terms neoliberalism) in the US and the UK since the 1940s. Stedman Jones has a bit of a burr under his saddle about Marxism, and he appears to interpret any historical account that stresses how the wealthy supported economism-type policies out of their own self-interest as a Marxist account. So he stresses the growth of economism as a set of ideas, promulgated by think tanks. He has to admit that these think tanks relied upon the financial support of sympathetic capitalists, but as far as he is concerned, that’s more of a footnote.

In connection with other research, I had my attention directed to the book by historian Kim Phillips-Fein, Invisible Hands: The Businessmen’s Crusade Against the New Deal (New York: Norton, 2009). It seems to me that this volume makes a nice bookend with Stedman Jones. Phillips-Fein is most interested in why the US business community (she does not address the UK) found it in its interests to support conservative counterattacks against the New Deal from the 1930s up to the eventual triumph of conservatism (and economism) with the election of Reagan in 1980. Where Stedman Jones focuses on the ideas and the think tanks, Phillips-Fein focuses on the organizing and proselytizing among the businessmen to raise the money to support these ideological and political movements. I would suggest that between them they provide a more thorough history of the US part of this story than either volume would by itself. (Phillips-Fein talks about Hayek, von Mises, Friedman, and the Mont Pelerin Society, but does not mention the terms ‘neoliberalism’ or ‘economism’—just another clue as to how the terminology issue continues to vex.)

In reading Phillips-Fein’s narrative, two themes especially struck me. First, if one looks at the later years of the conservative movement, one can find among the grievances of the business leaders specific instances of overreaching among labor unions and government regulators, for which the businessmen might be forgiven for thinking that the free enterprise system was under serious attack. However, in the very early years, before either unions or government had amassed that much power, we still see a core of conservative capitalists viewing the New Deal as an unmitigated disaster. As Phillips-Fein analyzes their thinking and quotes from some of their letters and speeches, what emerges appears to be a very basic sense of entitlement to rule. These white male business leaders seemed to think that they were, in fact, those chosen to run America, and they expected to be deferred to. The very idea that anyone else should demand an equal right to be heard, much less to guide public policy, was treated by them as a fundamental affront to their status. While various other segments of the population came along and joined the conservative bandwagon as it picked up steam in the 1960s and 1970s, these capitalists were at the center of it from the start.

Second, Phillips-Fein obviously exercised a lot of control over the quotes that she selected, but a rather surprising number of the quotes from these conservative capitalists, again reaching well back into the 1930s, are frankly racist. In keeping with the idea that they are the natural leaders and deserve deference on all sides was the further idea that minority groups had better stay in their place. As the conservative movement started to make headway, and as more politically-minded business leaders realized the need to form strategic alliances, the main groups this core of business leaders reached out to along the way were those that in various ways were opposed to integration and civil rights. Here Phillips-Fein’s poster child is the late Sen. Jesse Helms of North Carolina. To a person like me, raised in the North as a self-ascribed liberal, Helms was nothing but a racist demagogue, pure and simple. Phillips-Fein shows that in fact Helms was much more clever and original than that. He was actually a master at reframing Southern segregation into the language of freedom and free enterprise. For example, he agreed that to the extent that a lunch counter was a public service, blacks had just as much right as whites to sit down and be served. The only problem, he was quick to point out, was that a lunch counter was not properly viewed as a public service at all; a person owned the lunch counter and it was his private property. To demand that he serve black customers in the South was to demand that the Federal government could come in and dictate to private property owners what they could do with their property. Helms was shrewd about avoiding attacks against blacks and always changing the subject to freedom and opposition to Federal government power over local communities and private individuals.

In short, the political success of the conservative movement that ultimately enshrined economism as the common-sense political discourse of the US would never have succeeded had the movement not been willing to ally itself at every step with racism and segregation, while at the same time denying that it was racist and segregationist.

In one other passage, Phillips-Fein contributes to our list of logical inconsistencies within economism by going back to the core ideas of Friedrich Hayek and Ludwig von Mises. She notes the irony of their views of the free market and their need to protect it from any outside interference and efforts at regulation. On the one hand they were in awe of the power of the marketplace, “the spontaneity of the economy, a complex system that came into existence without forethought or planning.” Yet at the same time they saw the market as “a terribly fragile entity” which could be destroyed by even a little bit of government interference or regulation. As she notes, they never confronted or admitted, let alone explained, just how the marketplace could be so robust and all-powerful on the one hand and so delicate and vulnerable on the other.
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Reflections on the Metaphors We Live–and Die–By Sat, 19 Apr 2014 13:17:21 +0000 Read More »]]> 0 “Breakthrough Cures”? Reasons for Skepticism Fri, 18 Apr 2014 22:26:00 +0000 New England Journal, and mentioned in passing the appearance of antiviral drugs for hepatitis C that are being touted as new miracle cures. My focus in that post—
--was how our so-called free market fails to protect the public interest, so I looked only at the outrageous cost of the hepatitis C drugs and gave a free pass, more or less, to the “cure” claims.

In doing so I overlooked an older and a more recent blog post by our good pal Dr. Roy Poses at Health Care Renewal:

Dr. Poses takes care to show the extraordinarily flimsy evidence on which these new drugs are being ballyhooed. He says a number of things about study design and so on, all of which seem pertinent. But if we try to get a sense of the big picture, all I think we need to know is the natural history of hepatitis C. As Dr. Poses reviews for us, hepatitis C can be a very bad disease leading to liver failure and death. But the total number of folks with the virus who end up with this extreme version of the disease is not that large. A goodly number of people who carry the hepatitis C virus never develop any obvious disease at all. Another good chuck of them develop some liver inflammation, but it never develops into the extreme life-threatening forms.

So before one can get all that excited about a new treatment for hepatitis C, insofar as actual patient-centered outcomes are concerned, we’d need a large-scale follow-up study that showed that people getting the new drugs actually had improved health over the long haul. That would in turn depend on showing that the apparently decent (but hardly perfect) side effect profile of the new drugs is maintained long-term, else the chance of having a bad side effect might be as great as the chance one would have had the bad kind of rapidly-advancing hepatitis C infection with liver damage.

According to Dr. Poses who’s checked out the literature much more carefully than I have, what we know so far is that the new drugs do a pretty good job of clearing the hepatitis C virus from the bloodstreams of patients when followed for a period of up to 24 weeks.

It may well be that a drug that does this good a job of clearing the virus in the short term does an equally good job of saving the patient from long-term, serious consequences of having the virus. Or that may not be the case—we’ve seen many, many instances of initially promising treatments that ultimately fail to pass that test. (This may also be a good time here to remind ourselves of Dr. John Ioannidis’s warning:
--about how it’s a mathematical near-certainty that the first reports about any new drug will give an unduly rosy picture of its effectiveness.)

Now, let’s be fair to the advocates for the new drug. It will take years, to say nothing of tons of money, to do the studies needed to show the real effectiveness of these new hepatitis C drugs. So in the meantime, the data we have so far is probably what’s to be expected at this stage. And so far, the drug is performing more or less as one would expect if indeed it is going to turn out to be a breakthrough drug.

OK, I’ll buy all that. So how about some recognition of the actual limitations of what we know, when this drug is being talked about? Why should supposedly scientifically-aware advocates for the drug feel a need to talk like used car salesmen? (Unless, in fact, their ultimate goal is to sell us a clunker?)

So mea culpa for my earlier post, if I inadvertently added to the hype around these new drugs, instead of joining Dr. Poses in raising the appropriate skeptical concerns. One can hope that the drugs turn out to be what they are hoped to be; and one can also hope that somehow, if that’s the case, people who need them will be able to afford them.
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Surge in Narcotic Prescriptions for Pregnant Women Fri, 18 Apr 2014 18:17:50 +0000 0 Life before Anesthesia Fri, 18 Apr 2014 16:33:16 +0000 Continue reading ]]> 0 Genetic Testing in Torts Litigation – Justice or Injustice? Fri, 18 Apr 2014 14:54:00 +0000 Maya Sabatello]]> 0 What’s so good about Good Friday? Good Friday and Bioethics Fri, 18 Apr 2014 13:05:49 +0000 Read More »]]> 0 The History of US Drug Policy Since the Cold War Fri, 18 Apr 2014 12:53:00 +0000
Prof. Dominique Tobbell of the University of Minnesota has contributed Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences. She makes two basic points about our struggle today to reform drug policy, in a direction that brings pharmaceutical manufacture, research, and marketing better into line with public health and public interest. The first point is that this struggle is not new; basically the same issues have recurred ever since the end of World War II. The second point is that the pharmaceutical industry has never waged this battle against what it considers burdensome government regulation on its own; it has always had allies among medical organizations and academic physicians who had a strong interest in defending the status quo.

Prof. Tobbell points out that by the mid-1960s, the drug industry had achieved an impressive enough record in fighting off government regulation that the tobacco industry turned to Pharma for advice and help. During all those years, medical practitioners were primed by the AMA to fear the bogeyman of socialized medicine, and academic physicians worried about excessive federal influence over research policies. It was easy to get these fellow travelers on board when Pharma wrapped itself in the mantle of “free enterprise” and presented a less-regulated industry to Congress and to the American public as a bulwark against communism.

In the heady postwar days, when everyone was thrilled with the tremendous advances in antibiotic, hormonal, and psychiatric therapy, the climate of ethical thought was quite different from what reigns today. For example, Prof. Tobbell describes the efforts at the University of Pennsylvania to create a training program in clinical pharmacology in 1955: “Norman Topping, the university’s vice-president in charge of medical affairs, sought to create an institutional structure that would ensure the program could be responsive to the industry’s needs. Indeed, Topping believed the new program should function, essentially, as a service unit for the drug industry.”While today such a stance would at least raise some eyebrows, apparently no one gave it a second glance in the 1950s.

Similarly, when the National Academy of Sciences formed the Drug Research Board in 1963, to help conduct the massive amount of research required to implement the new FDA amendments Congress had just passed to require that drugs be shown to be effective as well as safe, some in Congress looked askance at the inclusion of scientists with strong industry ties. The Board basically pooh-poohed any such concerns, insisting that it was a great advantage to have these scientists as part of the effort because of their inside knowledge and policy smarts. Conflict of interest—who, us?

One theme that I have addressed at some length in earlier posts—most recently:
--is the impact of the ideology that I prefer to call economism and others call neoliberalism on today’s Pharma policy. Prof. Tobbell was kind enough to respond to an e-mail query, since I noted that the word “neoliberalism” is virtually absent from her volume. Consistent with her thesis, she states that the anti-government-regulation, pro-free-market stance that the drug industry has adopted was present all through the 1950s and 1960s. When neoliberalism/economism entered the US political discourse in a big way in the middle to late 1970s, Pharma was happy to hitch its wagon to that rising star, just as it was happy to jump on the anticommunist bandwagon in earlier decades; but one cannot say that neoliberalism played a major formative role in Pharma’s policy or strategic thinking.

Dominique A. Tobbell, Pills, Power, and Policy: The Struggle for Drug Reform in Cold War America and Its Consequences. Berkeley, CA: University of California Press/Milbank Books on Health and the Public, 2012.
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Pediatric Euthanasia Redux Fri, 18 Apr 2014 03:46:00 +0000 Read More »]]> 0 Yet More on Statins and the Recent Guidelines Thu, 17 Apr 2014 22:15:00 +0000
--and since my pals at Primary Care Medical Abstracts keep feeding me more ammunition, I wanted briefly to mention two more commentaries that take aim at the guidelines (subscriptions probably required to access).

First, John Abramson, who’s been mentioned here numerous times, and his colleagues wrote in BMJabout the CTT meta-analysis, on which the new guidelines heavily relied. They challenged the rosy picture painted by the CTT by drilling down and recalculating the CTT’s own numbers. The CTT, recall, claimed that if one carefully summed the data from numerous previous clinical trials (none of which showed any reduction in all-cause mortality from taking statins for primary prevention), you could see that statins in low-risk patients save lives and prevent strokes and heart attacks.

So when Abramson’s team went back and crunched the numbers themselves they found, for the populations included in these studies:

  • No significant difference in all-cause mortality
  • You’d have to treat 140 low risk patients for 5 years to prevent one heart attack or stroke
  • The studies overall either fail to report any adverse reactions to statins, or else report adverse reactions at a much lower rate than has been shown in independent (non-manufacturer-sponsored) studies. If the rates of adverse reactions in the independent studies are valid, it is very likely that the chance of suffering an adverse reaction from a statin is notably greater than the chance of preventing a bad outcome.
Skip now to another old acquaintance, John Ioannidis, commenting more recently in JAMA. Ioannidis addresses the new guidelines head-on and is more interested in two issues. One is the total global impact—he calculates as his title suggests that if applied across the world, the “statinization” of humankind would result in at least 1 billion folks being told they needed statins, which would be a huge impact on the health systems of those nations and would conceivably shift resources away from much more desperately needed stuff. The main issue Ioannidis focuses on is the risk calculator employed by the guideline—a calculator that’s new, and that was shown right from the get-go to have significant weaknesses, that have been since confirmed. He gives us the math to show why it’s not very reliable.

Ioannidis takes a step back then and asks the question—we’ve been in the business of trying to calculate risk of coronary artery disease for more than 30 years; so how come we still can’t get it right? He also notes that the decision on the part of the guideline writers that a 10 year risk of developing cardiovascular disease of 7.5% ought to be the cutoff for recommending statins is a completely arbitrary number, unsupported by any empirical evidence—the “right” number could be 2% or 20% for all we know.

What these commentaries have in common is that both point out how messed up the basic data are due to all the major studies being supported by the drug industry, and how serious conflicts of interest contaminate this entire enterprise.

Abramson JD, Rosenberg HG, Jewell N, Wright JM. “Should People at Low Risk for Cardiovascular Disease Take a Statin?” BMJ 347:f6123, 2013.

Ioannidis JPA. “More Than a Billion People Taking Statins? Potential Implications of the New Cardiovascular Guidelines.” JAMA 311:463-464, Feb. 5, 2014.
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Summarizing the “Market Failure” Special Issue of the New England Journal Thu, 17 Apr 2014 22:12:00 +0000 New England Journal of Medicine all combine to illustrate “market failure” in the pharmaceutical industry. As you can guess, the editors of NEJM didn’t adopt my suggested title for their issue. (See the end if you want more explanation as to why I’m calling it that.)

First is the editorial by Drs. Hoofnagle and Sherker—
--that talks about what would ordinarily be considered unalloyed good news elsewhere in the issue. Hepatitis C, which up till now has been quite resistant to treatment, appears to be well controlled by a new family of antiviral medications, with a minimum of side effects. This indeed appears to be one of those all-too-rare-today “breakthroughs” in drug treatment.

So what’s not to like? As the editorialists explain, the price tag. A complete course of one of the drugs comes in at $84,000, which works out to $1000 per tablet. The authors note a collision course between newly expanded public health efforts to do a better job of detecting the additional 1.6 million Americans who have Hep C and don’t know it, so that they can get this wonderful new treatment, which then many of them will not be able to afford—or if we could provide it for them, would break the bank of what the authors delicately call an “already overburdened medical care system.”The authors work for the NIH and as dutiful government employees are apparently discouraged from saying anything bad about the pharmaceutical industry, so they offer no ideas on what might be done about this problem.

Now jump to two “Perspectives” pieces in the same issue. One is from our good friends at the Harvard-Brigham and Women’s program in Pharmacoepidemiology and Pharmacoeconomics, including Dr. Jerry Avorn:

The P&P gang describes what has happened under a program begun by the FDA in 2007, the Risk Evaluation and Mitigation Strategy. The idea when this passed Congress was to speed the entry onto the market of useful new medications that also posed safety issues. If the company could come up with a special plan to limit the use of the drug in such a way as to lower the risk of adverse reactions, then the drug could go on the market. But the proviso added on was that this plan ought not be used as a way to stop generic products from entering the market later.

Unfortunately the amendments that passed Congress also included a monkey wrench that was virtually guaranteed to undermine this intent (assuming that Congress intended what they said, and that Pharma lobbyists did not rewrite the law in the back room). The company that developed this special safety plan for the new drug could also patent the plan.

So Dr. Avorn and colleagues list several cases where the drug company has sued generic competitors claiming patent infringement if the generic guys use the same safety plan, and also filing suit to stop any generic that uses a different safety plan as raising the risk level for the public unacceptably. The only sensible way to fix this problem, say the Harvard guys, is to use the same safety plan for all versions of the drug regardless of manufacturer, but to make this happen Congress would probably have to amend the 2007 act. Bottom line—a policy that was intended to allow patients access to drugs while assuring safety, that was not supposed to interfere with generics entering the market, is being used by Pharma precisely as an “evergreening” tool to prevent generic competition.

Now we come to another Perspectives article authored by Drs. Sham Mailankody and Vinay Prasad:

They also address the cost of new drugs, in this instance for cancer. Their basic point is—there are newly developed drugs for cancer treatment that provide small but apparently real benefits, such as an average extension of life by a few months. These drugs work by mechanisms very similar to old, generic drugs. (They give the example of the new drug abiraterone, which works in much the same way as an old anti-fungal antibiotic, ketoconazole.) So the ideal scientific question now to be asked is how well these same cancer patients would do if instead of getting the very expensive new drug, they got the very cheap old drug, ketoconazole. They might do just as well, or it might be that the new drug has some advantage—until we did the study we wouldn’t know.

The kicker that Mailankody and Prasad now note is—how would this new study be paid for? No way that the drug company that’s making a mint off abiraterone is going to bankroll a study that might pull the rug out from under its golden goose. So suppose some neutral investigators try to organize the study? Well, assuming that for the very same reasons, the manufacturer won’t just give away abiraterone for free (especially knowing for what purpose it’s going to be used), the investigators would have to pay market price and buy the drug. And the authors calculate that for a study large enough to answer the question of non-inferiority of ketoconazole, the cost of the drug alone—forget the rest of the cost of the study—would be about $69 million. In other words, no study of this sort will ever be done.

These authors also work for the NIH, and so are also apparently leery of saying anything controversial, and so don’t offer any proposals for a solution to this problem.


OK, so we have three articles in the same issue of NEJM, all of which have the same basic theme—in the name of profits, the drug industry is working contrary to the public health and the advancement of science. This is what old-time economist Kenneth Arrow famously called the market failure of health care—it simply does not follow the laws of supply and demand. Those who continue to extol the supposedly “free” market as the right way to manage all of our affairs, pharmaceuticals and health included, have to stick their heads in the sand and pretend that market failure never happens. As this blog has shown extensively, it happens all the time.]]> 0
Blowing Up Bioethics: A Response to Atrium’s Bad Girls and Head Nurses Thu, 17 Apr 2014 18:46:33 +0000 Rachelle Barina, MTS and Devan Stahl, MDiv

Northwestern Medical Humanities and Bioethics Program recently published its 2014 issue of Atrium, titled “Bad Girls.” In the issue, William Peace writes an article about “Head Nurses,” which is accompanied by an overtly sexual image (see page 20). “Head nurses” were women who gave young paralyzed men like himself blowjobs in the late 1970s. Peace describes “shapely young women” giving “world-class blowjobs” to men who were worried their “dicks” did not work and they could not “fuck.” Peace describes his own despair and his anticipated encounter with a “head nurse.” Peace nostalgically claims, “This woman was able to provide me a level of care and a connection that no longer exists.” “She reaffirmed my manhood and masculinity in a way I will forever appreciate.” “[T]he nurse injected a compassionate eroticism that made me a better man,” and ultimately, “…gave me myself”

Peace’s narrative is a worn-out and objectifying trope.…

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Manslaughter conviction for ‘negligent breastfeeding’ puts other mums at risk Thu, 17 Apr 2014 14:12:34 +0000 0 New Educational Primers to Accompany Anticipate and Communicate Thu, 17 Apr 2014 14:00:37 +0000 0 Bias, Bias, Bias (Part I) Thu, 17 Apr 2014 01:04:45 +0000 0 Have I Officially Become an Economist Now? Wed, 16 Apr 2014 18:57:07 +0000 Continue reading ]]> 0 7th Annual National Healthcare Decisions Day Wed, 16 Apr 2014 11:30:00 +0000 IT’S HERE!  Today is the 7th Annual National Healthcare Decisions Day! 

ACTIVITIES/RESOURCES:  Even if you have your own resources, please also direct patients, residents, clients, and the public to the resources at:  There are free resources that people can care with loved ones throughout the country.

FREE WEBINAR TODAY: at 3:00pm eastern, please join me, Ellen Goodman and others for an NHDD webinar.  Register at:

LEAD BY EXAMPLE: As always, please encourage others by your example.  Here’s a simple message you can send/post to your family and friends tomorrow:

Today is National Healthcare Decisions Day.  I have had a talk about advance care planning with my loved ones.  Have you?  Free information, forms, tools, and an incredible video are at:  Do it today.

SPREAD THE WORD FURTHER: Please share NHDD information with your members/contacts/colleagues by forwarding this email or a link to or NHDD on Facebook or Twitter or LinkedIn 

JOIN US:  If you are receiving this email second-hand (or have not previously confirmed participation), please let us know who you are by completing the short participant confirmation here:

DON’T FORGET THE REST OF THE YEAR:  NHDD is our rallying day, but advance care planning is important throughout the year.  Continue to use the NHDD resources and always be on the lookout for activities to make NHDD even better.   

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Patient Modesty: Volume 65 Wed, 16 Apr 2014 04:18:00 +0000 0 Look How Much Medicare Spends after Patients Leave the Hospital Tue, 15 Apr 2014 19:33:24 +0000 Continue reading ]]> 0 International Conference on End of Life: Law, Ethics, Policy and Practice – ABSTRACT DEADLINE Tue, 15 Apr 2014 15:46:00 +0000 From August 13-15  2014, the Queensland University of Technology in Brisbane, Australia will be hosting the International Conference on End of Life: Law, Ethics, Policy and Practice.  The call for abstracts closes Wednesday, April 30.

ICEL 2014 will provide a global forum at which health law scholars, bioethicists, legal and health practitioners, and health law and bioethics institutions can meet to discuss and present on law, ethics, policy and practice relating to the end of life. Abstracts on the conference’s four sub-themes are particularly welcome:
  • Withholding and withdrawal of potentially life-sustaining treatment (e.g. advance care planning, futile treatment)
  • Palliative care and terminal sedation
  • Euthanasia and assisted suicide
  • Determination of death and organ and tissue donation

Here are some highlights:
  • Debate on ethics of euthanasia and assisted suicide -- Professor Peter Singer, Princeton University & Assistant Professor Charles Camosy, Fordham University
  • How we die -- Dr Peter Saul, John Hunter Hospital & Professor Michael Ashby, Royal Hobart Hospital and Southern Tasmania Health Organisation (THO)
  • Withholding and withdrawing life-sustaining treatment -- Professor Jocelyn Downie, Dalhousie University
  • Panel sessions: Comparative flash points in end of life law, ethics and policy
  • Terminal sedation -- Professor Shelia McLean, Glasgow University
  • Determination of death -- Dr Dale Gardiner, Nottingham University Hospitals
  • Assisted death practice: Research from around the world

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Concussion Cases Inspire New Course at George Washington’s Law School Tue, 15 Apr 2014 15:00:07 +0000 0 Despite the Risks, and Because of Them, the FDA Should Permit Recycling Medical Implants Tue, 15 Apr 2014 14:54:00 +0000 Arthur L. Caplan]]> 0 Sorry Kid, But Your Mom’s in Jail for Having You Tue, 15 Apr 2014 14:45:41 +0000 ]]> 0 New Video Highlights the Need for a Plan When it Comes to Incidental Findings Tue, 15 Apr 2014 14:19:28 +0000 0 A Doctor’s First Words to a Patient Tue, 15 Apr 2014 04:29:00 +0000

“Interesting belt — where did you get that?”

“I see you are from Youngstown. The key question is, are you a Steelers fan or a Browns fan?”

Daniel R. Wolpaw, M.D., and Dan Shapiro, Ph.D. writing a Perspective article titled "The Virtues of Irrelevance" in the April 3 2014 issue of the New England Journal of Medicine present these as examples of possible opening remarks by a physician to a patient who appears with a medical problem.  The authors suggest that remarks such as these serve 4 "key purposes"  from the physician's point of view which, in establishing the doctor-patient relationship provide "ways to establish the connections that allow us to actually care for the person in front of us."  They explain: "First, they convey that we see the patient as a unique individual. Given the speed of medical practice, it is not surprising that patients worry that their individual concerns will not be heard. Second, these questions reveal that we have had shared experiences, that despite our training and attire we are not so different from the patient. Third, they communicate that we are observant and attending to details, which patients find comforting. And finally, they indicate that we are open to a conversation with the patient."

I am not going to start out with a detailed discussion on my part regarding the pros and cons of a physician beginning the doctor-patient relationship with what might seem as irrelevant communication. What I want to read is what my visitors to this thread think should be the opening question by a physician to their patient: "Tell me about your concerns" or something to that effect or instead to begin with "irrelevance" ..Maurice.

Graphic: Via Google Images from Wall Street Journal by Linzie Hunter and modified by me with Picasa 3.]]> 0
The Changing Legal Climate for Physician Aid in Dying Mon, 14 Apr 2014 20:21:00 +0000 0 On Parenting Adam Lanza, the Sandy Hook Shooter Mon, 14 Apr 2014 17:04:39 +0000 Continue reading ]]> 0 Visualizing Empathy: An interview with Laura Ferguson Mon, 14 Apr 2014 16:40:41 +0000 0 For the working poor, new health premiums can be a burden Mon, 14 Apr 2014 15:00:13 +0000 0 Guidance published on informing study participants about findings with potential health implications Mon, 14 Apr 2014 14:02:31 +0000 0 Why Health Coaching Helps Mon, 14 Apr 2014 03:04:15 +0000 0 Healing and the Kingdom Sun, 13 Apr 2014 21:20:39 +0000 Read More »]]> 0 Masters of the Universe: An Alternative History of the Rise of Economism? Sat, 12 Apr 2014 23:42:00 +0000
A colleague kindly referred me to this book review—

--of Masters of the Universe by the British barrister and historian Daniel Stedman Jones. (Both the review by Michael Clune of the Los Angeles Review of Books, and Stedman Jones’s book, refer to what I call ‘economism” as neoliberalism, so I will use “N” for short to refer to that terminology.)

Stedman Jones’s book can be read simply as another historical treatment of the rise of N during the era 1940-1980, in both the US and the UK, and as such it seems a reasonable and thoughtful volume. However, according to both the author and the reviewer, the agenda is more ambitious. Stedman Jones wishes to argue as to the inadequacies and indeed errors of other works, notably David Harvey’s A Short History of Neoliberalism, which some of my historian and social science colleagues treat as a standard reference on the subject, and Naomi Klein’s Shock Doctrine, upon which I relied considerably in writing THE GOLDEN CALF. So it naturally interested me to see how well Stedman Jones could defend his case as to the errors of those other authors.

Before that, what does Stedman Jones have to say? Very briefly, he argues that the route from N as a fringe philosophy held by a small number of thinkers in the late 1940s, to its triumph under Thatcher and Reagan in the 1980s, was not at all the slam-dunk that right-leaning thinkers now believe, nor was it the result of an organized conspiracy among capitalists as he thinks that Harvey argues. It was a long, slow slog that could easily have turned out differently. Stedman Jones places a lot of weight on what happened in the 1970s with economic doldrums and “stagflation,” which discredited in many politicians’ minds the long-standing Keynesian orthodoxy. First it’s important to note that just as Freud’s reputation was trashed at the hands of many Freudians, among the worst enemy of Keynes’s reputation were the Keynesians. While Keynes himself was quite cautious as to the ability of economics to predict and control events precisely, his followers grew fat and sassy and promised much more than their theories could deliver. Hence they were easy to discredit when supposedly Keynesian remedies failed to restore economic prosperity during those years.

Enter monetarism—Milton Friedman’s own theory of what to do in difficult economic times. The review stresses that monetarism and today’s N are quite different species of animal; N rejects government interference with the economy while monetarism is a method of government interference in the economy. Accordingly, the left-center governments in power in the UK and US in the late 1970s thought they could adopt monetarist policies without buying whole hog into anything like N. But because of both the economic doldrums and other events such as the Iran hostage crisis, these folks were then voted out of office and replaced by more extreme ideologues who bought the whole N deal—even though by today’s standards Reagan’s brand of N was considerably more moderate than the going ideology, and usually has to be spruced up with some revisionist history so that today’s N devotees can properly worship Reagan.

OK, so that’s the history, and knowing more about its ins and outs is certainly valuable. What about the criticisms of Harvey and Klein?

Harvey’s besetting sin, according to both Stedman Jones and Clune, is apparently being a Marxist, or at any rate what they consider to be a Marxist, which presumably translates into soft-headed. Looking into the details as to exactly how this invalidates Harvey’s historical writings, Clune offers the observation that Harvey apparently believes in a Marxist theory of labor that has long been discredited. I cannot recall, in my reading of his history, that whether he believed that theory or not made much difference for most of the book.

More to the point, Stedman Jones apparently wishes to attribute to Harvey’s Marxism, and not to a correct reading of history, the role that capitalists played in the rise of N. Stedman Jones’s account, as one would expect, is big on the role of N think tanks. And being a decent historian, Stedman Jones relates just who footed the bills for all those think tanks. And it was not the poor. So it’s not clear to me how Stedman Jones can on the one hand admit the crucial role of many capitalists, presumably following their own self-interest, to fund these N think tanks, and then turn around and say that capitalists had nothing to do with N’s eventual triumph.

What about Klein’s theory of the shock doctrine, which she attributes to Milton Friedman and his followers in the Chicago School of Economics? Well, Klein’s idea, as I understood it, was that the so-called “Chicago Boys” saw their opening whenever a nation suffered a crisis. They then showed up with their monetarist policies as a way to get the fiscal crisis under control. At first the offering seemed modest—a nation could adopt these monetarist policies without having to abandon whatever other political policies they wished to espouse. But then as soon as the technocrats took over, they used their opening to institute a wide range of “reforms” that completely instituted an N program, and that effectively repealed all the existing policies, especially any that favored organized labor. I don’t see much difference between such a program and what Stedman Jones says actually occurred under Thatcher and Reagan. Certainly one could quibble about details but the outline seems valid.

In short, Stedman Jones’s attempt to separate his own book from previous work seems more of a marketing ploy than a sober assessment of what he actually has on offer—and what he has on offer seems to be useful in its own right, and not in need of any such trumpeting.
Daniel Stedman Jones, Masters of the Universe: Hayek, Friedman, and the Birth of Neoliberal Politics. Princeton University Press, 2012.]]> 0
Very Preterm Baby Beats the Odds and Survives Sat, 12 Apr 2014 22:58:00 +0000 0 Honoring Choices Across Cultures: End of Life & Advanced Care Planning Sat, 12 Apr 2014 07:30:00 +0000 On Wednesday, May 7, the University of Minnesota will host a one-day conference:  "Honoring Choices Across Cultures: End of Life & Advanced Care Planning."

High quality advanced care planning and end of life care is essential to ensuring that patients do not receive unwanted care in their last days, weeks, and months of life. As our population ages and health care spending grows, this issue becomes more and more pressing. Health disparities exist between majority culture and minority cultures in many areas, including advanced care planning and end of life care. Discussions around these topics can be difficult in the best of circumstances, and language or cultural barriers can lead to poor quality or even damaging conversations that cause harm to patients or the provider/patient relationship. This course aims to address this challenging area of medicine.

This one-day conference will include didactic lectures in the morning. The afternoon will include small-group simulated patient encounters with live standardized patients, as well as small-group tabletop scenarios. The simulated patient encounters will allow learners to each be the provider leading  discussion with a patient or family member, followed by a small-group debrief led by a faculty expert.  Tabletop exercises will include discussions of common clinical scenarios facilitated by a faculty expert.

Upon completion of this educational activity, participants should be better able to:

  • Develop a framework for leading discussions with patients and families about advanced care planning and end-of-life care 
  • Review evidenced-based methods for cross-cultural bargaining and discussion 
  • Apply skills learned in didactic sessions to live simulated patient encounters 
  • Comfortably address advance care planning and end-of-life care when a language or cultural barrier exists.

7:30 – 8:00 
Registration and Continental Breakfast
8:00 – 8:15 
Welcome and Introduction to health disparities in Advance Care Planning - Brett Hendel-Paterson, MD, CTropMed
8:15 – 8:45 
Panel Discussion about cross-cultural approaches to advance care planning - Miguel Ruiz, MD; Mohamed Hagi-Aden, MD, Channy Som, (Interpreter)
8:45 – 9:30 
Advance Care Planning – Definitions and Best Practices - Drew Rosielle,MD FAAHPM
9:30 - 9:45 
9:45 – 10:15 
Introduction to Cross-Cultural Communication - Pat Walker, MD, DTM&H, FASTMH
10:15 – 10:45 
Cross-cultural bargaining and discussions of end-of-life care - Kathie Culhane-Pera, MD
10:45 – 11:15 
End of Life Care and Advance Care Planning – a practical framework for working across
cultures - Miguel Ruiz,MD
11:15AM – 12:00
12:00 – 1:00 
1:00 – 2:30 
Afternoon Session A*
1.) Sim-Center Cases
2.) Tabletop exercises (5-6 cases)
2:30 – 2:45 
Break and transition next group
2:45 – 4:15 
Afternoon Session B*
1.) Sim-Center Cases (3 cases)
2.) Tabletop exercises (5-6 cases)
4:30 – 5:00 
Group Debrief - Brett Hendel-Paterson, MD; Patricia Walker, MD

The Sim Center Cases will include three cases with professional standardized patients and debriefing led by an experienced teacher in palliative care or primary care. The cases will include one inpatient case, one clinic-based case, and one home-based case. Each participant will have the opportunity to be the lead provider for at least one case, and be an active observer in one or two other cases.

Tabletop Exercises will include small-group discussions of some common scenarios that arise in inpatient or outpatient medicine around advanced care planning and end-of-life care. Groups will be facilitated by a faculty expert in palliative care or primary care.

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Want More Proof That Correlation Is Overrated? Fri, 11 Apr 2014 15:07:13 +0000 0 What Role Should Bioethics Play in Global Health? Fri, 11 Apr 2014 14:54:00 +0000 Nicholas J. Diamond

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