Tag Archives: bioethics

The Journal of Medicine and Philosophy — August 2014

sports-doping

The August issue of The Journal of Medicine and Philosophy does not have a specific theme. The nine articles address a number of quite interesting issues, among them:

  • How existential psychotherapy can offer powerful insights to patients recovering from severe mental disorders such as psychosis
  • How a preference in athletics for natural talent over artificial enhancements (such as doping) may reflect “unsavory beliefs about ‘nature’s aristocracy’ ”
  • How rich, educated, white males may be just as, if not more, vulnerable to threats posed by physician-assisted suicide and voluntary active euthanasia than members of marginalized groups
  • When the decision is made not to administer artificial hydration and nutrition, can the responsibility for the patient’s death be attributed to the underlying pathology, even when that is not the cause of death
  • The right to procreate: Is it possible for prospective mothers to wrong prospective fathers by bearing their child

Note that the articles in this journal are not open access and that I have added the emphasis in the following extracts and abstracts. Read more

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Social history of medicine — August 2014

history-of veterinary-medicine

The August issue of Social History of Medicine contains eight original articles:

  • Late 19th/early 20th century food adulteration in an increasingly industrialized and globalized world and the search for safety standards
  • The shift in cancer education in the 1950s, no longer downplaying post-operative recovery
  • The 20th century shift in British veterinary medicine towards small animals (dogs, cats), as the need to attend to horses declined (open access)
  • How complaints about the quality of London drinking water in the 18th century reflected the new popularity of bathing for health and social attitudes towards bathers from the lower classes
  • A re-evaluation of the prevalence of venereal disease at the time of the World War I (open access)
  • How quacks preyed on people with hearing loss in mid-19th century Britain
  • How the 1975 TV play, ‘Through the Night,’ portraying what it was like to experience breast cancer treatment, registered with medical professionals and activists who complained of ‘the machinery of authoritarian care’ (open access)
  • Did Axel Holst and Theodor Frølich actually develop an animal model of experimental research?

There are also a large number of book reviews, including:

  • Writing History in the Age of Biomedicine by Roger Cooter with Claudia Stein
  • Emotions and Health, 1200–1700 by Elena Carrera (ed.)
  • The Age of Stress: Science and the Search for Stability by Mark Jackson
  • Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution by Robert Baker

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The Journal of Medicine & Philosophy – June 2014

cognitive-enhancement

The theme of the June issue of Medicine & Philosophy is disagreements among bioethicists. This is an interesting topic in its own right (see the extract from the Introduction to the issue below), plus there are a few articles that especially appealed to me. The discussion of cognitive enhancement appears to argue for a more tolerant attitude toward enhancement drugs based on an attitude of humility, plus toleration and transparency. There’s also an article that points out how we assume the art of clinical medicine is an innate skill and that, as a result, we fail to teach it.

Note that nothing is this journal is open access (and also that I have added the emphasis).

Introduction

Bioethics and Disagreement: Organ Markets, Abortion, Cognitive Enhancement, Double Effect, and Other Key Issues in Bioethics

Victor Saenz

I. BIOETHICS AND DISAGREEMENT

Bioethics was born in the 20th century out of an attempt to cope with rapidly and radically developing medical technologies, especially as they arose around the time of the Second World War. Albert R. Jonsen, one of the founders of bioethics, writes in reminiscence:

New techniques, from antibiotics to transplanted and artificial organs, genetic discoveries, and reproductive manipulations, together with the research that engendered them, presented the public, scientists, doctors, and politicians with questions which had never before been asked. (Jonsen, 2000, 115; cf. Jonsen, 1998)

But more importantly, bioethics arose as well due to major cultural changes that marginalized previous approaches to moral issues in health care and that brought into question medical ethics as an enterprise grounded in the medical profession. Read more

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For U.S. health care, some are more equal than others

death-rate-after-surgeryThe Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).

We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:

  • The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”
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Why do we feel bad about the way we look?

Laurie Essig’s new book, American Plastic: Boob Jobs, Credit Cards, and the Quest for Perfection, includes a chapter on how we learn to want cosmetic surgery. She quotes Joan Rivers, from her book Men Are Stupid . . . And They Like Big Boobs: A Woman’s Guide to Beauty Through Plastic Surgery:

My abiding life philosophy is plain: In our appearance-centric society, beauty is a huge factor in everyone’s professional and emotional success—for good or ill, it’s the way things are; accept it or go live under a rock.

Heidi Montag cultural texts promoting cosmetic surgery

Essig comments:

But Rivers is a TV star. TV and movie stars have always utilized the miracles of cosmetic surgery to look good in the two-dimensional spaces they inhabit. How did the rest of us learn to desire a perfectly plastic body? How did ordinary women and men with ordinary lives and ordinary bodies learn that they need plastic? The answer: the plastic ideological complex, a set of cultural texts that are both highly contested and yet tightly on message. It is itself so ubiquitous that it might even be described as hegemonic. In other words, the “need” for cosmetic procedures is impossible to avoid. Through advertising and TV shows, movies and magazines, we learn to want cosmetic intervention in our aging faces and imperfect bodies. This need is now so firmly implanted in our cultural psyche that it has become “common sense” to embrace cosmetic procedures. Why wouldn’t we want to look more beautiful, younger, thinner, more feminine, better? The question is no longer will you have plastic surgery, but when.

Accept plastic beauty or go live under a rock. Rivers isn’t just joking; she’s also doing the serious work of enacting the ideology of plastic, an ideology that we can no longer avoid. Even if we did live under a rock, whenever we crawled out from underneath it, we would be assaulted by images of perfectly plastic beauty on billboards and the sides of buses and on TV and in movies and even the nightly news. And then there are those damn magazine racks, an unavoidable gauntlet of Dos! and Don’ts! that must be passed through each and every time we buy our food.

A conspiracy of capital to make us feel bad

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Baby RB, Baby Isaiah, Baby Joseph

Baby Joseph MaraachliThese days, both the oldest and the youngest die in hospitals.

Baby RB suffered from a rare subtype of a genetic neuromuscular condition, congenital myasthenic syndrome, and spent his entire life – he was not yet two – on a respirator. After a protracted legal dispute between his health care providers in the UK and his parents (who disagreed on what should be done), he was allowed to die

Baby Isaiah was born with his umbilical cord wrapped around his neck after 40 hours of labor. He suffered severe and irreversible brain damage. He was kept alive for four and a half months. Following a legal dispute with health care providers in Canada, his parents agreed to allow their child to die.

The current case in the spotlight is Baby Joseph Maraachli. He suffers from a “progressively deteriorating neurological condition” of unknown origin and is in a permanent vegetative state. He is 13 months old. A court in Ontario ruled that the health center treating Baby Joseph could remove the breathing tube keeping him alive. The parents have transferred the child to a hospital in St. Louis, where he will receive a tracheotomy. The story has received extensive coverage in Canada and is just beginning to show up in the US press.

According to Reuters:

Rebecca Dresser, a professor of law and medical ethics at Washington University in St. Louis, said U.S. courts generally side with families in such cases that want to continue treatment for loved ones even in seemingly hopeless medical cases.

Dresser said similar end-of-life cases will likely become more common.

“Because of the growing concerns about costs, we’re going to see more of this,” she said.

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The ethics of a neuroenhanced future

NeuroscienceImplementing the discoveries of modern brain science raises ethical issues. For example: (emphasis added)

Issues of personhood and authenticity, for example, have become hotly debated among neuroethicists as pharmaceuticals developed for improving mental health disorders, sleeping disorders, or attention disorders in children are now being consumed at high rates as off-label “cognitive enhancers” to boost mood, memory, and alertness. If these drugs, or substances like oxytocin, become the Viagra of daily functioning and create new benchmarks for productivity, wakefulness, and emotional love, what will happen to the fabric of society and the character of our interactions with one another? Are these altered states a genuine reflection of a new and improved “me” or “we”, or some transient drug-induced condition that thoroughly confounds what we inherently value? Will we be coerced into conforming to a wave of drug intervention in the ever expanding, do-it-yourself, self-help world? The race for cognitive enhancers poses questions of social justice as well. Will the opportunity gaps between those who can afford them and those who cannot be widened or narrowed?

[H]ow shall scientists, physicians, legal scholars, policy makers, and society at large manage new tests that may soon be able to forecast with acceptable reliability unacceptable levels of risk for aggression, sociopathy, psychopathy, and suicide?

With advanced capabilities, will an integrated understanding of the genetics and brain biology of these conditions [Alzheimer’s, schizophrenia, addiction, anxiety, stress] … plunge those affected into fatalistic states of hopelessness out of which they feel they cannot ever emerge?

Entrepreneurs will surely lose no time in selling the technology directly to consumers who may be curious for what they interpret to be a neurogenetic signature or fearful about their neurogenetic status. What, and how much, would you want to know? At what personal and financial cost?

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Character, personality, and cosmetic surgery

IntegrityI am not a blogger. I know what Andrew Sullivan and the Huffington Post people say about how one should blog: Think of it as a conversation and just write what you would say to a friend. I can do that in a comment, but not in a post. It doesn’t suit my “personality” – and personality is a topic in this post.

But … I wrote a comment that got so long, it seemed like it should be a post. It’s a reply to something Roberta said in a comment on Wang Bei and cosmetic surgery.

[T]here is a personality or psychological need within some people that drives them to have plastic surgery to fill a hole inside them. I think people who seek fame and want to go into the entertainment industry, like Wang Bei, by and large have a certain personality type. And it is largely based on a need for constantly being in the spotlight, and a need for constant applause or approval. The roots of these needs would be many and complex, but could include genetics and parenting style.

Here’s my reply. Read more

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The death of Wang Bei: Cosmetic surgery as a moral choice

Wang BeiIn my customized Google news, I have a category for cosmetic surgery. Most items that turn up are self-serving PR announcements, but recently there was lengthy coverage of the death during cosmetic surgery of aspiring Chinese pop star Wang Bei.

The details are tragic: She was only 24. Ironic: She was already beautiful. And dramatic: Her mother was having the same procedure at the exact same time. So her mother woke up to discover her daughter was dead. Or perhaps not. According to conflicting reports, her mother was told nothing until the next day. The news reports out of China do not strike me as especially reliable.

For example, Wang Bei’s death was first reported as an anaesthetic accident, but the majority of stories describe the cause of death as bleeding from the jaw. Wang was having facial bone-grinding surgery “to make her jaw line fashionably narrow and her face smaller.” (Chinese women are said to prefer an oval face shaped like a ”goose egg.”)

The blood from Wang’s jaw drained into her windpipe, and she suffocated. Is that an “anaesthetic accident?” Wang’s surgeon claims the operation was a success and that Wang died of an unexpected heart problem several hours after the procedure. Read more

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Palliative care: Lost and recovered

Victorian deathbedHere’s an excerpt from the third and last part of the interview with me by Dr. Lisa Marcucci at Inside Surgery. The question asked for a little known fact from the history of medicine.

Easing the pain of death was a common medical practice in the 19th century. The doctor’s black bag contained laudanum as early as the 1600s. The 19th century added morphine (1806), codeine (1836), and aspirin (1892), along with the anesthetics chloroform and ether. At a time when physicians had very little to offer patients by way of cures – other than the ineffective “heroic” measures of bloodletting and purges — it was palliative care that made physicians welcome at the deathbed.

In those days, easing pain at the time of death was not called palliative care, but euthanasia. The term referred to the outward death of the body, in contrast to the death of the spirit. Euthanasia literally means a good death.

In 1870 a school teacher named Samuel Williams published an essay that used the term euthanasia to mean something else: mercy killing. The essay generated considerable interest and discussion. To make a long story short, the original meaning of the term euthanasia was completely lost.

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A raffle for free (human) eggs

In vitro fertilization

Source: Babble

At a London seminar promoting American donor eggs for infertile British women, a Virginia infertility clinic offered attendees the chance to win an American woman’s eggs. Also included was a free in vitro fertilization (IVF) cycle (a $23,000 value). The reaction, on both sides of the Atlantic, was mixed.

According to The Washington Post, there has been “intense criticism from infertility experts, bioethicists and others in Britain and the United States, who likened the event to a crass, commercial come-on similar to a lottery, with the prize being a human body part.”

“We strongly have the view that using a raffle to determine who will receive treatment with donor eggs is inappropriate,” said a spokesman for the Human Fertilization and Embryology Authority, which regulates infertility care in Britain. “It trivializes altruistic donation, whether of eggs, sperm or embryos.”

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Baby Isaiah’s parents expect second child

There is some happy news for the parents of Isaiah May, who died earlier this month after being removed from life support. Isaiah’s mother, Rebecka, reports that she is now pregnant with her second child.

Baby Isaiah was born after 40 hours of labor with his umbilical cord wrapped around his neck, depriving his brain of oxygen. He was unable to breathe without a ventilator, and doctors determined that he was severely brain damaged. Born on October 24, 2009, his parents’ legal battle to keep him on life support received considerable publicity, especially in Canada. In the end, his parents agreed to remove their child from life support before being forced to do so by a legal court order.

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Actions surrounding the moment of death are highly symbolic

losing-a-childIn a recent article in The New England Journal of Medicine entitled “Is It Always Wrong to Perform Futile CPR?”, a doctor describes the case of a baby boy who had been born with a large encephalocele on his forehead – a neural tube defect that allows the brain and its surrounding membrane to protrude outside the skull. The child survived surgery to remove the growth, but was left effectively brain dead (“neurologically devastated”).

The doctor, Robert Truog, a professor of medical ethics, anesthesia and pediatrics at Harvard Medical School, had cared for the boy when he was repeatedly admitted to the intensive care unit. The parents had been advised to limit the boy’s care to the relief of pain, but they insisted that doctors treat the child aggressively and do everything they could to keep him alive. The boy had survived the first two years of his life.

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Baby Isaiah May, October 24, 2009 – March 11, 2010

Baby Isaiah May was allowed to die today, in the arms of his parents. The child was surrounded by 10 family members, including a grandmother who had traveled from Washington State.
Today was the date set for the next court appearance in the May’s attempt to keep their child alive. In statements after last month’s legal proceedings, the parents suggested they might be planning to make this decision on their own, rather than leave it up to the courts. And that’s what happened today. The court appearance was canceled.

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Olbermann on the damage done by "death panels"

Last October, in a one-hour special commentary on health care reform, Keith Olbermann discussed his father’s illness in personal and graphic detail. Last night he provided an update that began: “Last Friday night my father asked me to kill him.”

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Olbermann and his father have had conversations about end-of-life care. He’s outraged at those who oppose this emotionally difficult but medically important event.

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Baby Isaiah: February update

Four-month-old Baby Isaiah suffered irreversible brain damage at birth when his umbilical cord wrapped around his neck. Medical authorities recommended that the child be disconnected from the ventilator that keeps him alive. Isaiah’s parents have sought to keep their child on life support through the legal system. See here and here for previous posts on Baby Isaiah.
A medical expert had agreed to give his opinion on the case on February 19. The upshot of last week’s court proceedings, however, was another delay. The medical expect requested an additional MRI and more time to confer with specialists. A new court date has been set for March 11.

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Baby Isaiah: Ethical dilemmas of modern medicine (2)

Baby Isaiah James May

Source: Rant Rave

As I described in a previous post, the parents of Isaiah James May, who has been declared brain dead, are engaged in a legal battle to keep their son on life-support. At their last court appearance on January 27 they were granted an extension of their appeal. The next court date is set for February 19, when a medical expert will testify.
For updates on baby Isaiah, there is a Facebook page (available if you’re a member of Facebook). The page mysteriously disappeared on Friday, but was restored on Sunday. Curious. The site includes three videos: A diaper change, baby Isaiah moving his leg, and a thank you from the parents. Although the parents find the movement of his leg an encouraging sign, I found that particular video – which shows the baby’s feeble movement, as if in slow motion — quite sad.

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Baby Isaiah: Ethical dilemmas of modern medicine (1)

Baby Isaiah James May

Source: The Province

Isaiah James May was born last October in a small town (population 7,000) in Alberta, Canada. For Rebecka May, age 23, this was her first child. The pregnancy was normal, and both mother and child were healthy at the time of delivery.
Labor was difficult, however. It went on for 40 hours, including four hours of pushing. It’s not clear why a Caesarian section was not performed. When baby Isaiah finally appeared, his umbilical cord was wrapped around his neck. This had deprived him of oxygen, and he suffered severe and irreversible brain damage.
The child was flown to a children’s hospital in Edmonton, where he was placed on a ventilator. After evaluating Isaiah’s condition, doctors recommended removing him from life support. His parents took the matter to court, and Isaiah remains on a ventilator and feeding tube, pending a legal decision.

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Baby RB: Ethical dilemmas of modern medicine

In the days before informed consent – when doctors knew best and it hadn’t occurred to patients that they had rights – newborn babies with life-threatening birth defects were declared “stillborn.” The motives were compassionate: Spare the parents an agonizing choice and a lifetime dedicated to full time care. This medical practice continued well into the post-World War II era.
Today, due to a combination of technological advances in medicine and the rise of bioethics, that’s not what happens. Premature babies, for example, can be kept alive. Those first few months may be very difficult on the parents psychologically, and — if they have good health insurance — may cost a million dollars, but premature infants are saved all the time.

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Were "death panels" a teachable moment for palliative care?

This past summer, thanks in large part to Sarah Palin, we were inundated with sound bites about death panels, pulling the plug on grandma, and saving the government money by dying a little sooner.
Palin’s emotionally manipulative Facebook post appeared on August 7. “The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care. Such a system is downright evil.”
A great deal of misinformation was bandied about, and unnecessary fears were purposely inflamed to gain political advantage. There may be a silver lining to this cloud, however.

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Keith Olbermann & the Fight against Death

The thing about Keith Olbermann is, I tend to agree with his positions far more than I care for his over-the-top, full-of-himself histrionic shtick. So I approached his “Special Commentary” on health care — one hour of nothing but the largest talking head on TV — with both interest and trepidation.
Olbermann called his Special Commentary “Health Care Reform: The Fight Against Death.” Over and over again he returned with a flourish to the word “death,” the subtext being “Look how heroic and iconoclastic I am to be talking about this unmentionable subject.” The inevitability of death was his scare tactic: “You are going to die. We are all going to die.” Yet at the same time, he accused his opponents of exploiting that same fear: The reason misguided folks are opposed to reform are the “death panel” scare tactics of the other side.

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