Saturday, December 24, 2011

'Tis the Season

I'll be blogging very little in the next few days, as I'll be celebrating the season with family--and grading! Pace will kick up again near the end of the month.

Wednesday, December 21, 2011

EU Bans Export of Death Penalty Drugs

The European Commission has moved to limit the export of barbiturates to countries which, like the United States, use the drugs in lethal-injection death-penalty executions. Some individual countries and some pharmaceutical firms have already restricted export to death-penalty states, resulting in a serious shortage; this move by the EU will restrict supplies still further. Sadly, I imagine that resourceful death-penalty states will simply move to using other drugs; but perhaps the need to reconsider their methods of execution will lead some states to reconsider the death penalty entirely.

Tuesday, December 20, 2011

Bioethics Poetry, Donald Hall Edition


To grow old is to lose everything.
Aging, everybody knows it.
Even when we are young,
we glimpse it sometimes, and nod our heads
when a grandfather dies.
Then we row for years on the midsummer
pond, ignorant and content. But a marriage,
that began without harm, scatters
into debris on the shore,
and a friend from school drops
cold on a rocky strand.
If a new love carries us
past middle age, our wife will die
at her strongest and most beautiful.
New women come and go. All go.
The pretty lover who announces
that she is temporary
is temporary. The bold woman,
middle-aged against our old age,
sinks under an anxiety she cannot withstand.
Another friend of decades estranges himself
in words that pollute thirty years.
Let us stifle under mud at the pond's edge
and affirm that it is fitting
and delicious to lose everything.

Donald Hall

Two Tales of Conjoined Twin Separation

In one story, two once-conjoined toddler girls are heading back to the Dominican Republic, having been successfully separated by a day-long surgery that divided their liver, pancreas and other shared organ systems and reconstructed their abdominal walls. Virginia Commonwealth University had a farewell party for them. In the other story, one of two girls separated at Santiago, Chile's Calvo Mackenna Hospital has died, and her sister is said to be in stable but critical condition. The two, who had had a shared intestine and liver, had been struggling since their 18-hour separation surgery in early November.

The decision to attempt to separate conjoined twins is an ethically challenging one. First, there are the medical risks. Sometimes separation is simply out of the question; sometimes it is medically required if one or both of the twins are to survive infancy. Often, though, separation is surgically possible, but risky. The question then arises, "What risks should parents submit their children to for the sake of bodily normalcy?" An additional problem arises if the medical risks of separation are not be shared equally between the twins: May one twin be put at risk, or even sacrificed, for the sake of the other's attaining a more "normal" life?

There are also some very complicated questions about the motivations of the parties seeking separation. After all, many twins have lived happy lives without separation, and a certain amount of desire for separation may be driven by social pressure for bodily normalcy and biases against disability. (Parents and medical personnel can, of course, share those social attitudes.) More troubling is the possibility that the separation surgery is being pressed by physicians or hospitals for the sake of publicity or reputation-enhancement.

To be clear: I cannot tell from the media coverage which of the above questions or ethical problems were in play in either of the two stories I cited above. It's just that the simultaneous stories, with their very different outcomes, put me in mind of this set of issues.

Canadian AIDS Researchers Oppose HIV-Exposure Prosecutions

The current CMAJ includes this letter from three researchers at the British Columbia Centre for Excellence in HIV/AIDS, arguing for an end to Canada's criminal prosecution of people who allegedly expose sexual partners to HIV. The letter points out that the actual risks of transmission to sexual partners are quite low for well-controlled HIV; that prosecutions have never been shown to reduce rates of infection: and that they may in fact discourage or interfere with HIV testing and treatment. In this interview, one of the co-authors also notes that while Canadian rates of prosecution for HIV exposure have been on the rise, there is no similar policy of prosecuting those who expose partners to other potentially serious viruses like HPV.

About Comments

I welcome comments on my posts, and will try to respond to substantive points. But I will (continue to) delete any comment that 1) is obscene or offensive or 2) links to a commercial site.

Republicans De-fund Needle Exchanges

House Republicans have restored the ban on US federal funding of needle-exchange programs--programs which have been proven effective, time and again, at reducing HIV and hepatitis transmission, and which therefore also reduce the costs of medical care. Art Caplan has more here.

Insurance Reform Successes

This report from the Centers for Disease Control shows that provisions of the Obama health insurance reform law which went into effect in 2010 have resulted in an additional 2.5 million young adults (19- to 25-year-olds) having insurance coverage. And while we're talking about provisions of the health reform law that are already helping people, let's not forget the reduced Medicare Part C premiums and the Medicare "doughnut-hold" drug rebates for the over-65 set; the no-copay, no-deductible preventative care; the low-rate "pre-existing condition" insurance pools that have allowed some seriously-ill people to find coverage; the tax credits for small businesses who insure their workers; the restrictions on insurance-company limits on what they'll spend on the seriously-ill; and the limits on health plans' ability to spend premium dollars on marketing and administration. All of these benefits are already flowing from Obamacare. If people knew what was in it, they might be less anxious to ask judges to strike it down.

Freelance Sperm Donor

Here's an interesting story: a San Francisco bay-area engineer is being told by the FDA that he has to stop giving away his sperm to infertile couples. The FDA objects to the fact that the donor is not getting a blood test prior to each donation, as required by federal regulations. The donor, who promotes his free service on the web, decided to donate to couples on his own rather than through a clinic because he wasn't interested in payment for donation, wanted to give away his sperm for free, and didn't want the donor anonymity offered by clinics. He's interested in the possibility of playing a role in the lives of his children--which may keep him busy in the future, given that he's fathered 14 since 2007.

Thursday, December 15, 2011

More on Chimps in Research

Now Francis Collins says NIH will abide by the IOM consensus committee's guidelines about use of chimps in biomedical and behavioral research. That was fast!

GMC Will Draft Guidance on Assisted Suicide

According to this report in The Guardian, the UK's General Medical Council is planning to issue new guidance for investigation of physicians who've allegedly assisted a patient in suicide. The problem is in part with uncertainty over what sorts of actions by doctors really count as assisting in suicide. Is a sympathetic conversation enough to count as "assisting"? How about a factual assertion about the availability of assisted suicide in Switzerland? Some physicians' words or actions may not lead to criminal charges, but may nonetheless lead to complaints about their fitness to practice; a handful of investigations of this sort have already been conducted.

GMC plans to publish the guidelines for public comment next month.

Shocking US Rape Statistics

This CDC report of the results of the National Intimate Partner and Sexual Violence Survey finds that 1 in 5 American women, and 1 in 71 men, are raped in their lifetimes. The vast majority of female rape victims are raped before age 25, mostly by intimate partners. Over a quarter of male victims are raped before age 10.

Presidential Commission Report on Protection of Human Subjects

The Presidential Commission for the Study of Bioethical Issues has released its report on protection of human subjects. This is the follow-up to September's report on the unethical studies done by the US Public Health Service in Guatemala in the 1940s. Major recommendations in the new report seem to be for better data collection and transparency by funding agencies, and for provisions guaranteeing that subjects injured in research are compensated for their research-related medical care.

Institute of Medicine Approves Limited Use of Chimps in Research

The much-awaited Institute of Medicine consensus report on the use of chimpanzees in biomedical and behavioral research is here. Bottom line: chimps may be used in biomedical research if no other models are available, if it would be unethical to conduct the research in humans, and if failing to do the research would significantly slow progress toward control, prevention or cure of a debilitating or fatal disease. The panel split on whether chimps could be used in hepatitis research. Comparative genomic and behavioral research should be permitted, the report says, only if it would yield otherwise unattainable insights into behavior, genomics or mental health; and may only be conducted on acquiescent animals using minimally invasive techniques that minimize pain and distress.

The report is bound to upset animal-rights activists; but it also appears to be full of arguments for much sharper limits on, and better oversight of, chimpanzee use in research.

Update: I neglected to note that the report says, in no uncertain terms, that most current chimp research is unnecessary, and fails to meet the guidelines I mentioned above.

Wednesday, December 14, 2011

Doctor's Conflict of Interest

This is a wonderful, and subtle, discussion of what it was like for an MS patient to discover that her treating physician had long been on the payroll of the pharmaceutical firm which made the drugs he'd been asking her to take.

Bioethics Poetry, William Carlos Williams Edition

The Last Words of My English Grandmother

There were some dirty plates
and a glass of milk
beside her on a small table
near the rank, disheveled bed--

Wrinkled and nearly blind
she lay and snored
rousing with anger in her tones
to cry for food,

Gimme something to eat--
They're starving me--
I'm all right--I won't go
to the hospital. No, no, no

Give me something to eat!
Let me take you
to the hospital, I said
and after you are well

you can do as you please.
She smiled, Yes
you do what you please first
then I can do what I please--

Oh, oh, oh! she cried
as the ambulance men lifted
her to the stretcher--
Is this what you call

making me comfortable?
By now her mind was clear--
Oh you think you're smart
you young people,

she said, but I'll tell you
you don't know anything.
Then we started.
On the way

we passed a long row
of elms. She looked at them
awhile out of
the ambulance window and said,

What are all those
fuzzy looking things out there?
Trees? Well, I'm tired
of them and rolled her head away.

William Carlos Williams

Tuesday, December 13, 2011

America's Health Rankings

It appears that I live in the third-healthiest of these fifty United States. Vermont's the best, Mississippi the worst. This site from United Health Foundation actually has a wealth of health data on each of the states: obesity rates, smoking rates, infant mortality, infectious disease. Enjoy!

More on Abortion and Mental Health

Michael Cook at BioEdge is making the mistake I blogged about briefly last week!

Here's the issue: This review study from the National Collaborating Centre for Mental Health (NCCMH) finds that while unwanted pregnancies have a negative effect on women's mental health, the mental health of women with unwanted pregnancies was no different whether they had an abortion or gave birth.

Now, 98% of all UK abortions are performed to preserve the physical or mental health of the mother; of those, 99.96% involve mental health. Should we infer, with BioEdge and with the Christian Medical Fellowship, that those abortions are inappropriate, because the NCCMH study proves that abortion doesn't preserve mental health after all?

We should not. NCCMH looked at rates of mental health problems among women who had had unintended pregnancies, some of whom had chosen to terminate them with abortion, and some of whom had given birth. It found similar rates of mental health in those two populations. But the women in those populations were in them by choice. The study does show that women who choose abortion have no better or worse mental health than those who do not. But it certainly doesn't show that their mental health would have been the same if the option to abort had been denied them, and they had been forced to give birth. The study, in other words, leaves open the question whether abortions are good for the mental health of the women who choose them.

Too Much Spending on Healthcare, Not Enough on Social Services

Here's a remarkable op-ed by my colleagues Betsy Bradley and Lauren Taylor. (Among many other things, Betsy runs Yale's Global Health Leadership Institute and Lauren is an alum of our Bioethics Summer Program.) Their piece summarizes data from a study that ran in BMJ Quality and Safety earlier this year.

The US famously spends very much more on healthcare than other countries. But the study looked at social spending more broadly, counting expenditures not only on health, but also on social services such as rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support, and so on. When those expenditures are added up, the US comes in 10th in world spending. And we're one of only three industrialized countries which spends more on health care than on those other social services. This failure to spend on social services, the op-ed claims, explains why our huge expenditures on health care don't give us good health outcomes. We'd get more health for our dollars if we offered people more social support.

A striking example from the op-ed: 119 chronically homeless people in Boston logged 18,884 emergency room visits in just five years, at a cost of $12.7 million. Perhaps if those people had had better social services, we wouldn't have had to pay for so many costly ER visits.

"Postcode Lottery" for Healthcare

The 2011 NHS Atlas of Variation is out! And sure enough, it shows dramatic variation in healthcare utilization and in GP practice patterns around the UK. North Lancashire doctors, for example, prescribe 25 times as many pills for dementia as those in Kent. Only 3 of every 100,000 people in Devon and Cornwall are admitted to NHS care homes, while in Northumberland that number is 190. Peterborough has an angioplasty rate treble that of County Durham. Coverage here and here.

The US has regional practice variation which is just as dramatic; it's been documented for decades by the Dartmouth Atlas of Healthcare, whose creator, Jack Wennberg, is the father of regional-variation research.

NHS has a webpage collecting different countries' medical-variation atlases here.

Friday, December 9, 2011

Abortion Doesn't Affect Mental Health

A new study from the Academy of Medical Royal Colleges' National Collaborating Centre for Mental Health (NCCMH) finds that, while unwanted pregnancies place women at risk for mental health problems including depression, the rates of mental health problems among women with unwanted pregnancies remain the same whether they have abortions or give birth. The finding certainly undercuts anti-abortion arguments about the prevalence of "abortion regret" and the supposed negative mental-health consequences of abortion. An important question is whether it also de-legitimates the idea of "abortion for the sake of the mental health of the woman." (A Christian Medical Fellowship spokesperson is quoted making that argument near the bottom of this article.) But that's a misreading of the findings. The women in the studies that NCCMH reviewed weren't, after all, randomly sorted into "abortion" and "birth" groups. Each chose her own best all-things-considered option given the fact of the unwanted pregnancy, her own moral views, her doctor's advice, pressure she was receiving from partners or relatives, and so on. The fact that the "abortion" and "birth" groups had similar mental-health outcomes therefore certainly doesn't imply that the outcome would have remained similar if all the women who chose to have abortions had instead been denied them.

Friday Frivolity, Genetic Determinism Edition

Thursday, December 8, 2011

Tobacco Warnings and the First Amendment

This piece by Kevin Outterson in the New England Journal of Medicine is an excellent overview of the tobacco industry's ongoing attempts to get the cigarette-packet warning provisions of the Tobacco Control Act declared unconstitutional.

Bioethics Poetry, Dylan Thomas Edition

Do Not Go Gentle Into That Good Night

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on that sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

Dylan Thomas

Morning-After Pill: Contrasting News

President Obama defended HHS Secretary Sebelius's decision yesterday to override the FDA's recommendation that morning-after contraceptive pills like Plan B be made available over-the-counter to women and girls of any age. Critics were accusing Obama of having directed the override in order to avoid controversy during the upcoming election. Obama today said that he wasn't in on the decision, but that he approved of it, "as the father of two daughters." As a result of the override, the drug will remain behind pharmacy counters, available without a prescription only to women over 17 years of age. Proponents of the FDA's plan saw its main advantage in putting the drug out on the pharmacy floor, where sexually active women could easily locate it, rather than in making it available to young girls; one expert observed that "not many 11-year-old girls" go into drugstores to buy anything, let alone single pills that cost $50.

Meanwhile in the UK the British Pregnancy Advisory Service is offering to make morning-after pills available free to women over 17 via post, after a preliminary telephone interview with a nurse ensures that they understand the pill's use. The charitable organization, which is the UK's largest abortion provider, is urging women to stock up in advance of the holidays, when unwanted pregnancies occur with higher-than-average frequency. The pills are sold online and in pharmacies to girls and women over 16, and are widely available, free of charge, in doctors' offices and NHS clinics.

Medical Journalism!

Presidents live longer! Nuns should use contraceptives! Smoking can make your nipples fall off! Eating cake makes you hairy! Yawning is a compliment!

Wednesday, December 7, 2011

Physician Assisted Suicide in Massachusetts?

This weekend the delegates at the annual meeting of the Massachusetts Medical Society affirmed their longstanding opposition to physician-assisted suicide. Lynda Young, M.D., president of the Society, described physician-assisted suicide as "inconsistent with the physician’s role as healer and health care provider."

Meanwhile it appears that Dignity 2012 will succeed in its efforts to get a "Massachusetts Death With Dignity Act" on the next state ballot. The Act, if approved by voters, would establish an Oregon-style assisted suicide regime in the state.

Patient Access to Medical Records

I blogged briefly the other day about the new plan to give all NHS patients access to their own medical records online. A few more thoughts:

In the short run, making medical records available to patients will give rise to a great deal of GP/patient friction. Patients won't understand what they read, and will ask for explanation. Some patients will be shocked and offended at the way physicians have characterized them (as frightened, as uncomprehending, as unwilling to discuss certain topics, as obese, and so on). Patients may not understand why a doctor hasn't written down their whole story, or accepted their version of events. A certain number of hours will inevitably be given over to discussion of what patients find in their medical records when they are first made available. (Of course, some of this might be quite healthy--patients, for example, may well discover and correct various errors or omissions in their medical histories.) In the longer run, the availability to patients of medical records will cause doctors to write and to use them differently. Gone will be the comments on patients themselves, and the notes-to-self about options to think about trying. Medical records will become cleaner, clearer, public documents; and at the same time will become a bit less useful for doctors. For that reason, I predict, doctors will come up with other ways--perhaps even extra-legal ways, but in any case ways outside the four corners of the medical record--to note their informal impressions about patients and their families.

NSW, Australia Considers Eliminating Organ Donor Family Veto

A new discussion paper from the New South Wales (Australia) Ministry of Health raises the possibility of eliminating the veto-power over organ donation that families of potential organ donors currently hold. NSW has the largest donor registry in Oz, but that hasn't translated into high transplantation numbers, largely because 45% of families choose to veto the harvesting of organs from their loved ones who'd signed up to be organ donors. This article summarizes some responses to the proposal. Transplant Australia, Kidney Health Australia and the Australian Medical Association all line up in favor of the change, but, interestingly, a spokesman for transplant lobby group ShareLife opposed the move, arguing that it could undermine people's willingness to sign up to be donors, and pointing out that the countries with the most successful transplant programs (Spain, Portugal, Croatia) all respect the wishes of the family. What matters isn't the legal regime, but the quality of communication with the families.

The discussion paper also raises the possibility of moving from the current opt-in system to a "presumed consent" system where patients would have to opt out of donation, but it does so only formally, noting (correctly) there's little international evidence in favor of making that move. Finally the paper suggests scrapping the NSW Roads and Maritime Services donor register and transferring its content to Medicare's national register.

Plan B Availability Blocked by Sebelius

FDA Commissioner Margaret Hamburg has just released a statement on the FDA's plan to allow the emergency contraceptive Plan B to be sold over-the-counter to women and girls of all ages. FDA found the drug safe and effective for emergency contraceptive use, over-the-counter, for all women and girls of child-bearing potential. But then--this morning--came the politics. From Hamburg's press release:

"[T]his morning I received a memorandum from the Secretary of Health and Human Services invoking her authority under the Federal Food, Drug, and Cosmetic Act to execute its provisions and stating that she does not agree with the Agency’s decision to allow the marketing of Plan B One-Step nonprescription for all females of child-bearing potential. Because of her disagreement with FDA’s determination, the Secretary has directed me to issue a complete response letter, which means that the supplement for nonprescription use in females under the age of 17 is not approved. Following Secretary Sebelius’s direction, FDA sent the complete response letter to Teva today. Plan B One-Step will remain on the market and will remain available for all ages, but a prescription will continue to be required for females under the age of 17."

Tuesday, December 6, 2011

All Men Are Mortal, Hard Drive Edition

MIT's Sebastian Seung has some bad news for transhumanists: there are some serious obstacles to your ever uploading your brain to a computer.

Patient Access to Medical Information

A group of health-related federal agencies have proposed a new regulation which would permit clinical laboratories to release test-results to patients who request them. (Currently 39 states either have no state law explicitly permitting such release to patients, or have laws mandating release only to physicians or other healthcare providers.) The current JAMA has a thoughtful analysis of some the questions raised by the new rule. The regulation is supposed to decrease physician workload, reduce the number of patients who never receive test results, and improve follow-up rates. But there are a lot of questions: will patients understand their test-results? will they experience needless anxiety over results that are abnormal but inconsequential? is it useful for patients to receive test results on their own, without medical interpretation or counseling?

Meantime, in the UK, Her Majesty's Treasury has announced in its Autumn Statement (p. 40) that all NHS patients will have online access to their own medical records by the end of this parliament (that is, by 2015). This raises a lot of questions about security and privacy, of course; but also about whether patients may be pressured into supplying their records to third parties.

Monday, December 5, 2011

Obese Child Seized by State, UK Edition

I blogged last week about the 200-pound eight-year-old who was removed from his mom in Cleveland and sent into foster care. Seems that it's not only in the US that public health officials are removing children from families who let them become too overweight. Here's an article about a five-year-old from Tameside, Greater Manchester, UK, removed from home for similar reasons; this child appears to be the youngest, but is by no means the first, to be seized from parents by UK health officials by reason of obesity.

Art Caplan has of course commented, and I have to agree: "You don't take someone out of the house and away from their parents unless they have an immediate risk of death."

Is foster care really a less expensive and more effective option than offering counseling and assistance to the child's parents?

Clone Me A Mammoth!

A team of Russian and Japanese scientists plan to use bone marrow from a recently-recovered woolly mammoth thigh bone to clone a living wooly mammoth--within five years! The team plans to create a mammoth embryo via Dolly-the-sheep style nuclear-transfer cloning, and transfer it to a "surrogate" elephant mother for gestation and birth. No word yet on the price-per-skein of mammoth yarn.

NHS to Share Patient Data With Industry?

Prime Minister David Cameron will give a speech today in which he'll announce plans for NHS to share its wealth of patient data with private industry, in order to boost the health sciences industry and speed up drug development. The government has assured critics that patient data will be properly anonymized, but there are already protests to the effect that privacy protections won't be adequate, firms will be able to re-identify private health information, and so on. In the same speech, Cameron will announce increased support for and use of tele-medical patient monitoring, and a program to give cancer patients and other seriously-ill patients early access to as-yet-unlicensed drugs.

Friday, December 2, 2011

NHS: Disclosing "Death Pathway" Use

The NHS's "Liverpool Care Pathway"--known to some in the press as the "death pathway"--is a palliative care pathway designed to reduce burdensome end-of-life medical interventions including, controversially, artificial nutrition and hydration. Tens of thousands of patients annually are put onto the pathway in the last days of their lives. But a new report claims that in a quarter of hospital trusts, one in three families are never informed that their loved one has been placed on the Liverpool Care Pathway. In one trust, fully half of families weren't informed. The good news is that doctors do discuss the issue with families in 94% of cases overall--a sharp improvement over the 2008-09 audit figure of 75%, even though twice as many patients are put on the protocol now than then.

Hershey School Rejects HIV+ Student

The AIDS Law Project of Pennsylvania has filed a lawsuit against the Milton Hershey School for disadvantaged students on grounds that the school violated the Americans with Disabilities Act when it rejected an applicant explicitly on grounds of his being HIV+. A statement from the residential pre-K to 12 school said: "In order to protect our children in this unique environment, we cannot accommodate the needs of students with chronic communicable diseases that pose a direct threat to the health and safety of others." "We are serving children," a spokesman for the school said, "and no child can be assumed to always make responsible decisions that protect the well being of others." This seems like a pretty clear ADA violation to me.

Friday Frivolity, What Patients Hear Edition

Thursday, December 1, 2011

Ninth Circuit Approves Bone Marrow Payment

The US Ninth Circuit Court of Appeals has determined that the federal ban on selling organs does not apply to bone-marrow donors who use modern marrow-donation technology. The once-painful procedure has now been replaced by a procedure resembling blood donation. Instead of removing actual marrow from the donor's bone, physicians now remove marrow precursor cells from the donor's blood--and the National Organ Transplant Act does not restrict payments for blood donation. The holding permits MoreMarrowDonors, a California nonprofit, to move forward with a program to offer $3000 scholarships, housing allowances or charitable donations as inducements to bone marrow donors.

Argentina: Toward "Dignified Death"?

Argentina's Lower House has passed, by a wide margin, a "dignified death" bill. The bill, which is still to be debated in the Senate, would permit patients with irreversible conditions or terminal illness to make informed refusal of lifesaving or life-sustaining medical interventions, including nutrition and hydration. Incompetent patients' wishes could be expressed by a defined set of eligible proxy decision makers (family members and partners). The bill would also relieve medical professionals of liability for following patients' wishes.

Bioethcs Poetry, Galway Kinnell Edition

Parkinson's Disease

by Galway Kinnell

While spoon-feeding him with one hand
she holds his hand with her other hand,
or rather lets it rest on top of his,
which is permanently clenched shut.
When he turns his head away, she reaches
around and puts in the spoonful blind.
He will not accept the next morsel
until he has completely chewed this one.
His bright squint tells her he finds
the shrimp she has just put in delicious.
Next to the voice and touch of those we love,
food may be our last pleasure on earth—
a man on death row takes his T-bone
in small bites and swishes each sip
of the jug wine around in his mouth,
tomorrow will be too late for them to jolt
this supper out of him. She strokes
his head very slowly, as if to cheer up
each separate discomfited hair sticking up
from its root in his stricken brain.
Standing behind him, she presses
her check to his, kisses his jowl,
and his eyes seem to stop seeing
and do nothing but emit light.
Could heaven be a time, after we are dead,
of remembering the knowledge
flesh had from flesh? The flesh
of his face is hard, perhaps
from years spent facing down others
until they fell back, and harder
from years of being himself faced down
and falling back in his turn, and harder still
from all the while frowning
and beaming and worrying and shouting
and probably letting go in rages.
His face softens into a kind
of quizzical wince, as if one
of the other animals were working at
getting the knack of the human smile.
When picking up a cookie he uses
both thumbtips to grip it
and push it against an index finger
to secure it so that he can lift it.
She takes him then to the bathroom,
where she lowers his pants and removes
the wet diaper and holds the spout of the bottle
to his old penis until he pisses all he can,
then puts on the fresh diaper and pulls up his pants.
When they come out, she is facing him,
walking backwards in front of him
and holding his hands, pulling him
when he stops, reminding him to step
when he forgets and starts to pitch forward.
She is leading her old father into the future
as far as they can go, and she is walking
him back into her childhood, where she stood
in bare feet on the toes of his shoes
and they foxtrotted on this same rug.
I watch them closely: she could be teaching him
the last steps that one day she may teach me.
At this moment, he glints and shines,
as if it will be only a small dislocation
for him to pass from this paradise into the next.

Globe and Mail on End-of-life Care

I'm grateful to Thaddeus Pope for drawing my attention to the Globe and Mail's amazing current series on end-of-life care.

There are two current important cases on end-of-life care pending in Canada. I blogged earlier about Gloria Taylor's case rising from British Columbia, which is challenging, for the first time since the Rodriguez case in 1993, the constitutionality of Canada's law against assisted suicide. The second case is that of Hassan Rasouli, a patient in a permanent vegetative state in Toronto. Rasouli's medical team wants to discontinue aggressive care and begin palliative care, but the patient's family disagrees. Lower courts held for the family, but the doctors have now appealed to the Supreme Court.

Garden Sheds, Men's Health, Weeds

So it turns out, according to NHS, that the recent claims in articles in the Daily Mail and the Sun to the effect that garden sheds are good for men's health are based on, well, a slight misinterpretation of an article in BMJ which actually dealt with "men's sheds," an "Australian skills and wellbeing programme that provides a place for male-focused activities outside work, not just a small building at the end of the garden."

Nonetheless, this song by John Williamson may reveal a different connection between shed's and men's health. Something to do with medical marijuana, I think.