Friday, September 21, 2012

Bioethics Poetry, Charles Lamb Edition

On an Infant Dying as Soon as Born

I saw where in the shroud did lurk
A curious frame of Nature's work.
A flow'ret crushed in the bud,
A nameless piece of Babyhood,
Was in a cradle-coffin lying;
Extinct, with scarce the sense of dying;
So soon to exchange the imprisoning womb
For darker closets of the tomb!
She did but ope an eye, and put
A clear beam forth, then strait up shut
For the long dark: ne'er more to see
Through glasses of mortality.
Riddle of destiny, who can show
What thy short visit meant, or know
What thy errand here below?

The poem continues here.

Thursday, September 20, 2012

Friday Frivolity, Another Breaking Bad News Edition

In case you missed one, all the past Friday Frivolity's are here.

Bad News on Vaccinations

This letter to the New England Journal of Medicine reports an increase in the rate of non-medical exemptions from the childhood vaccinations generally required by state law. (Non-medical exemptions are permitted in 48 of the 50 United States.) States that allow "philosophical," as opposed to only "religious," exemptions to mandated childhood vaccinations, had higher rates of exemption, as did states with "easier" opt-out provisions. Easy opt-out states allow parents to opt out of the vaccination requirement by filling out a standardized form supplied by the school; harder opt-out provisions require an original and/or notarized letter from the parent, or a form obtainable only from the state health department.

For whatever reason--but certainly including unscientific vaccine/autism fear-mongering--there has been a dramatic decline in US parents' willingness to vaccinate their children. The result has been the return of deadly childhood diseases including pertussis, whooping cough and measles. Vaccination is among the most effective public health measures. Certainly, states should make it harder for parents to opt out of vaccination programs for non-medical reasons. But rates of opt-out are on the rise even in "difficult" opt-out states, and there is some evidence that when states make it hard to opt out of vaccination for non-medical reasons, parents respond by pressuring doctors to write them bogus "medical" excuses.

The root of the problem seems to be that vaccines are victims of their own success. Most people haven't seen the effects of the awful childhood diseases that vaccines have been so effective at eradicating. But they've heard about vaccine reactions, and have heard all the unsubstantiated--or downright fraudulent--claims about vaccines and autism. How many kids will have to suffer or die with whooping cough or measles or pertussis before the public can be persuaded to trust in some of the most reliable science in all of public health?

Physician Interpretation of Industry Funding

According to this article in the current New England Journal of Medicine, physicians are more apt to prescribe drugs supported by studies they perceive as rigorous, than those supported by studies perceived as less rigorous. More interestingly, though, physicians downgrade their perception of the rigor of a study, their confidence in its results, and their willingness to prescribe the studied drug, when the study discloses that it was industry-sponsored. Physicians surveyed were twice as willing to prescribe a drug supported by an NIH study than one supported by an industry-sponsored study.

In general I greet this as good news. Industry sponsorship injects bias into the literature in many ways: via unconscious biasing of sponsored researchers, via careful selection of the kinds of studies sponsored (e.g., avoidance of head-to-head drug comparisons that have any chance of turning out badly), and even (in a few documented cases) via the burial or abandonment of sponsored studies that don't work out. So it's fine if physicians greet industry-sponsored trials with some skepticism.

Two worries, though: first, there can be too much of a good thing. After all, if a company develops a drug that really works, it will want to sponsor studies to prove that fact; and too much skepticism of positive results could end up hurting patients. Second, if industry sponsorship gives rise to skepticism, then there's an incentive to bury the fact of industry sponsorship via ghost authorship or other means.

Study registers, publication of negative results, rigorous authorship standards, rules for disclosure of funding sources and of conflicting interests, public funding for independent research: these can all help.

But the facts are 1) that we rely on private, profit-motivated research to find our new drugs; 2) that such research has historically done an excellent job in discovering and publicizing useful new drugs; and 3) that the very same motives that drive the industry to do a good job in discovering and publicizing useful new drugs are those that drive it to pollute and bias the literature. So there will be no easy answers.

Tuesday, September 18, 2012

Tom Koch on Bioethics, Oily-faced Edition

Okay, so Tom Koch thinks that, as a bioethicist, I'm an "oily-faced official worthy" who pretends to a care I don't deliver. Really, he does. Wait--does my face look shiny to you? Should I be worried?

Hmm. Maybe not. After all, Tom Koch also thinks that when we bioethicists argue that we're needed because the old ethics of medicine won't serve in the new world of advancing medical science and technology, we call that the "Georgetown Mantra." But when I google "Georgetown Mantra," I find people discussing somethng completely different!

And Tom Koch also thinks that bioethicists' "primary training is in philosophy, not biology, genetics, or medicine." He thinks this in spite of that fact that there are more physicians than philosophers on the current ASBH board, and more physicians than philosophers among the 200 or so Hastings Center Fellows. Maybe Tom Koch's beliefs are not all correct.

It's hard to tell, exactly, but Tom Koch seems also to think that bioethics has its roots in the "Regan" (sic) administration and its "postmodernist economics." I guess Tom Koch must think of the Hastings Center as a real field leader, being founded under Nixon and all.

And look! Tom Koch also thinks that "[b]ioethicists rarely work with patients," in spite of the fact that 100% of all US hospitals with over 400 beds, and 81% of all US hospitals regardless of size, have some kind of clinical ethics consultation service. It must be that Tom Koch thinks those clinical ethics consultants aren't bioethicists....

Wow! Tom Koch also thinks "some and perhaps many" bioethicists promote "a eugenic present and future, pruning the human tree, as "rational" by which is meant cost efficient." Some? Perhaps. Many?

Tom Koch also thinks that bioethics as a field has promoted a reductive consumerism in medicine, and has cast patients as consumers whose care ought to depend on their resources. I don't think we know the same people. Or read the same books. Or journals.

No, I'm not going to worry after all. Tom Koch doesn't seem to know much about bioethics, or about my skin--except how to get under it.

Bioethics-y Things at Yale: Killer Kitty edition

On Thursday, September 27 at 4:15 PM, our Animal Ethics Forum will host its first-ever public lecture. Clare Palmer (Philosophy, Texas A&M) will speak on "Ethics, Conservation, and Animal Welfare: Wildlife and Outdoor Cats." Outdoor cats, you say? Well, yes, actually. Our little purring murderers are estimated to kill 4 billion animals a year in the US alone. We humans are having a huge environmental impact via our cats. Clare's talk will raise a number of tough issues: the tensions among animal lovers and environmentalists, the limits of our personal responsibility, the meaning of animal suffering.

The event is co-sponsored by the Yale Interdisciplinary Center for Bioethics and the Yale Divinity School.

So Good to Be So Young!

Ah, what a relief: according to this survey, I'm not yet middle-aged!

Thinking About Fracking at Yale

This afternoon at 4, Yale School of Forestry and Environmental Studies will host what looks like an excellent panel entitled "Hydraulic Fracturing: Bridge to a Clean Energy Future?" The panel will feature John Hofmeister, a former Shell Oil executive and CEO of Citizens for Affordable Energy; Bill McKibben, an environmental journalist and founder of the grassroots climate campaign; Sheila Olmstead, a fellow at the nonpartisan think tank Resources for the Future; and James Saiers, F&ES professor of hydrology and a water chemistry expert. These people will not agree with one another.

Brad Gentry, director of the Center for Business and the Environment at Yale and a member of the F&ES faculty, will be the moderator.

The event will be held in the Burke Auditorium of the Forestry School's Kroon Hall. Details are here. If you can't make it to New Haven in time, don't worry: you can watch the event via live-streaming video here.

This isn't a Yale Interdisciplinary Center for Bioethics event, but given the unusual breadth with which our Center reads the "bio" in bioethics, it's exactly our kind of issue. Hope you'll join me in watching!