Saturday, September 28, 2013

Melissa Harris-Perry Appearance: My Not-Quite-15 Minutes of "Fame"

Here I am on Melissa Harris-Perry's MSNBC show, talking with a very sensible panel about end-of-life care. The two segments below do an excellent job of introducing audiences to my nascent bald spot. Plus I say some stuff; and a number of other people say some stuff too. I pretty much endorse all the stuff they say.  Comment on how said stuff was received willl follow shortly.

Visit for breaking news, world news, and news about the economy

Visit for breaking news, world news, and news about the economy

Finally, something to make my children practice....

A new study by Ines Jentzsch at St. Andrews shows that playing a musical instrument may protect against mental decline though age or illness. Time to pick up that pennywhistle again!

Saturday, July 27, 2013

An Interesting Infographic on Jobs in Public Health

A bit tough to read in places, but worth a look!

Why Public Health

Wednesday, July 17, 2013

Abortion in Ireland

For the first time, Ireland will permit abortion in some circumstances. First, abortion is permitted when there is a real and substantial risk of loss of the woman’s life from a physical illness. (The law has special provisions regarding emergency situations.) Second, abortion is permitted when there is a real and substantial risk of loss of the woman's life by suicide. Two physicians need to attest to the risk of loss of life from physical illness; three to the risk from suicide. The law includes a conscience clause relieving any physician from participation in the procedure or the determinations relating to risk of loss of life. Text of the law is here. Context-giving coverage from the Guardian is here.

The new law is a baby-step compared to other countries' laws. There is still no provision for abortion in the case of rape or incest, or fetal anomaly; much less for abortion based on the woman's desire not to have a child. But the law is explicit in not limiting the woman's right to travel to obtain an abortion, leaving open the woman's option to travel to the UK for abortions not permitted under Irish law.    

Wednesday, May 15, 2013

Informed Consent: Cool PEG tube video edition

Here's a great Youtube video on PEG tube placement; it seems to be up as a marketing move by the company that made it. Is there any reason why patients and their families shouldn't always watch something like this in connection with informed consent for any procedure? BTW, I have no connection to Nucleus Medical Art, I just think it's a great video. Of course, it's not the whole of informed consent--someone contemplating PEG placement for a loved one with advanced dementia, for example, ought to be given data about whether PEG feeding actually increases lifespan. But videos like this are a great way to tell patients about procedures.


Somatic Cell Nuclear Transfer Used to Create Human Embryonic Stem Cells

A international team including scientists from Oregon Health & Science University and the Oregon National Primate Research Center have just announced in Cell that they have successfully used somatic cell nuclear transfer (SCNT) to develop human embryonic stem-cell lines. As I understand the paper, the team removed genetic material from the core of multiple oocytes from two different human donors, and replaced it with nuclear material taken from the skin cells of an embryo. Some portion of the eggs from each donor then proceeded to develop to the blastocyst stage, at which point their cells were plated and tested for pluripotency. Pluripotency was proven when the cells, injected into immuno-deficient mice, formed tumors containing tissue- and cell-types representing all three germ layers.This paper, then, is the most powerful proof of principle to date that we may one day be able to combine SCNT and embryonic stem-cell technologies to generate made-to-order, genetically-compatible replacement tissue for humans with diseases such as diabetes or Parkinson's.

It's important to note that the blastocysts were imperfect in various ways, and could not have successfully been implanted into a woman to make a child. (Members of the same team have not yet been able to create a cloned monkey embryo capable of implantation.) This has created some verbal problems that will no doubt be fodder for the culture wars. Strangely, the mostly-liberal National Public Radio is reporting that the scientists created and destroyed human embryos, while the mostly-conservative Wall Street Journal is saying that the team's achievement "is a long way from creating a human embryo."

Here's how I think of it: while the team used cloning technology to create human embryonic stem cells, they didn't exactly create and destroy a human embryo along the way; they created what they knew to be a faulty approximation of a human embryo, but one close enough to the real thing to generate pluripotent human embryonic stem-cell lines. (Think of the fact that human embryonic stem-cell lines can also be generated from parthenotes which are completely incapable of developing into embryos.)

Nonetheless, I'm pretty sure these scientists would have no problem with creating a perfect, and in principle perfectly implantable, human blastocyst--though they have no intention of implanting one, and no research oversight body anywhere would permit them to, even if they did. They want to generate tissue, and if perfecting human embryo cloning helps them do that, they will. Even if you agree with me that the toughest ethics questions aren't quite yet raised by this work, this work certainly implies that they'll be raised sooner or later.

Vermont Legislature Passes Physician-Assisted Suicide Law

The Vermont legislature has passed a new physician-assisted suicide law and is sending it to Governor Shumlin, who supports it and is expected to sign. The Oregon-style legislation will be the third such state law in the country and the first adopted by a legislature, as opposed to via popular referendum. The strange feature of this law, though, is that while it begins by mandating (in section 5283) a number of Oregon-like anti-abuse measures to make sure that the program doesn't help the wrong people to die by mistake (two different oral requests, 15 days apart; a written request for self-administered lethal medication signed by two disinterested witnesses; findings of terminality and capacity entered into the chart; and so on), most of these requirements sunset in 2016 in favor of the much shorter section 5289, which says only:

"A physician with a bona fide physician–patient relationship with a patient with a terminal condition shall not be considered to have engaged in unprofessional conduct under 26 V.S.A. § 1354 if:
(1) the physician determines that the patient is capable and does not have impaired judgment;
(2) the physician informs the patient of all feasible end-of-life services, including palliative care, comfort care, hospice care, and pain control;
(3) the physician prescribes a dose of medication that may be lethal to the patient;
(4) the physician advises the patient of all foreseeable risks related to the prescription; and
(5) the patient makes an independent decision to self-administer a lethal dose of the medication."

A subsequent section immunizes any physician from civil or criminal liability for any actions performed in good faith compliance with the law.

The legislators's assumption, according to press coverage, is that physicians will have developed adequate professional standards for physician-assisted suicide by 2016. I wonder whether the law's repeal of safeguards will really last, or whether the Vermont legislature will re-think the matter in the next year....

And I know, I'm supposed to say aid-in-dying, not physician-assisted suicide. But I'm an academic, not an advocate, and even though the term "suicide" scares some folks, and others argue that it's not really suicide if you're dying of a disease you didn't choose, my own view is that if you give a terminally ill person some pills with which she can kill herself faster than her underlying disease would have, you're assisting in her suicide. (Wow! On that one verbal point, I actually agree with Wesley Smith! Though, unlike him, I approve of physician-assisted suicide with appropriate safeguards, and think that the Oregon safeguards are appropriate. And I'm not a fan of slippery-slope arguments.)

Friday, May 3, 2013

Friday Not-So-Frivolity: Sherlock Holmes Alzheimer's edition

This is in fact a lovely sketch, funny at the start and then just plain moving. It's the final bit with which Mitchell & Webb closed their last show.

Friday Frivolity: Not Intolerant to Wheat Edition

Thursday, May 2, 2013

Our Voting Public: Uninsured revolt against the Anti-Christ behind the climate hoax edition

An April survey from Kaiser Family Foundation found that four in ten Americans (42%) are unaware that "Obamacare" is actually the law of the land. 12% thought the health reform measure had been repealed by Congress, 7% thought it had been overturned by the Supreme Court (which actually upheld the law in June of 2012), and 23% didn't know enough to say whether the law was in force or not. Overall, 49% of Americans didn't know enough to say whether the law will impact their own families--but, depressingly, the percentage of people lacking that knowledge was highest in the two groups the law is likely to benefit most: the uninsured (of whom 58% said they didn't know how the law would affect them) and the poor (56%).

Another poll--from PublicMind at Farleigh Dickinson University--shows that 29% of all Americans (18% of Democrats, 27% of Independents, and a whopping 44% of Republicans) believe that an armed revolution might be necessary in the next few years, in order to protect our liberties. An armed revolution. In the next few years. Another 5% of Americans aren't sure about that. Well, that's good, I guess; one doesn't want to decide these things too precipitously.

And in other polling news from what appears to be this planet, Public Policy Polling (a well-respected polling firm known for asking the occasional oddball or controversial question) has found (among many other amusing and/or scary things) that 58% of Republicans think global warming is a hoax, while 77% of Democrats disagree; and that 20% of Americans think vaccines cause autism, while 34% aren't sure.

And 20% of Republicans believe that President Obama is the Anti-Christ. Well, I guess we know why they think armed revolution might be necessary. Hope your health insurance covers gunshot wounds.  

Monday, February 11, 2013

Monday, January 28, 2013

Medical Causes of the Sexual Revolution

Prof. Andrew Francis, an economist at Emory, is claiming that penicillin, rather than The (Birth Control) Pill, was the drug that gave us the sexual revolution of the 1960s. The idea is that the post-war availability of penicillin reduced the cost (to both partners) of intimate contact, by substantially reducing the risk (to both partners) of contracting an STD--especially syphilis. This effectively lowered the cost of sexual activity, inducing more people to engage in it (the benefits remaining more or less constant). An easily-accessible version of the story appears on the CBS news site, here.

Let us not lose sight, however, of the vital importance of The Pill. I have spoken personally with women of the 60s generation who were admitted to medical school (imagine this!) only after they'd told an interviewing dean--an actual Dean--that they were on The Pill, and that they didn't intend to let a pregnancy interfere with their progress through medical school, or with their entry into medical practice. "A medical school education, after all," the argument went, "is expensive not only to the student, but also to the faculty and to the government which (at least in the US) has substantially subsidized it for decades; why should we offer it to someone who will quit (and waste the investment) the moment she has a child? We're rather more inclined to enroll you if you can guarantee that you won't have a child--that is, if you tell us you're on The Pill, or will have an abortion if The Pill fails." The assumption, of course, was that if a woman were to have a child, it would be she, rather than her partner, who would give up on her profession and waste the investment made by others in her career. The idea of the working mother--though it was a reality for many working-class Americans--wasn't yet acceptable to Americans of the professional class.

Like access to birth-control, the abortion right announced in Roe v. Wade made it easier for professional schools to admit women. It meant that women could legally prevent themselves from having children whose rearing would interfere with their professional careers. They could control their reproduction even if their efforts at birth control had failed. (Remember, please, that men were *never* asked whether their having children--whether in or out of wedlock--would interfere with their taking full advantage of their educations.)

Punchline: Yes, Professor Francis, it may well be that penicillin did more than The Pill to facilitate the Sexual Revolution--by which we might mean, the widespread acceptance of pre-marital sexual relations. But it was for The Pill  (and the abortion right) to translate that newfound sexual freedom into sexual equality.

Tuesday, January 22, 2013

Harvard Prof Isn't Recruiting Neanderthal Moms

Oh, good. This story isn't true. There isn't actually a Harvard professor who wants to recruit a woman to bear a Neanderthal child from an embryo constructed, using stem-cell and cloning technology, from Neanderthal bone DNA. Turns out there was some translation error in the account of his interview with a German magazine. And the professor is upset. He's not actually proposing to clone a Neanderthal baby; he only thinks the issue should be up for discussion. For several years.
Oh, good.

Quick, Effective Public Health Measures

I'm freshly back from the annual meeting of the Public Health Law Research program, sponsored by Robert Wood Johnson.

At most academic meetings, I prefer schmoozing in the halls to listening to the talks. That's part personal vice, and part stage-of-career: at this point, it matters more who I talk to than whose paper I hear. This conference was different, though--perhaps because I'm new to it. A very large percentage of the papers (and posters!) repaid close attention.

But the best session of the conference, to my mind, was the "Critical Opportunities" session. The session, which is apparently an annual affair, is presented as a competition: a handful of public health law scholars are invited to present their best ideas for high-impact, evidence-based public health interventions that have a chance at actual enactment. The audience votes on which one they think is (to put it roughly) most worth peddling to health-policy folk under the banner, "Do it now!"

This year's choices: a proposal for corn masa flour fortification for the prevention of neural tube defects, made by the CDC's Erica Reott, MPH, LCDR S. Kinzie Lee, MPH, and Amy Cordero, MPA; a proposal for legal reforms to prevent opioid overdose from Corey Davis of UNC Chapel Hill; a proposal from Adam Finkel, Sc.D., of UPenn Law, to make "smart disclosure" rules, like nutritional content labels, more complete and accurate; a proposal to put decals on the cars of teens subject to "novice drive" license restrictions, from Allison Curry, PhD, MPH, of Children’s Hospital of Philadelphia; a proposal for better (and better supported) local governance of public health institutions from Scott Hays & Janine Toth of the University of Illinois at Urbana-Champaign; and a set of proposals for gun-control laws from Marvin Swartz, MD, of the Duke University School of Medicine.

All of the proposals were terrific and important, but I want to take a bit of time to mention a few that might surprise my blogging audience, as they surprised me. I leave aside the Hays/Toth proposals about public health governance, though they were completely sensible and apt to have immense impact over time; and I leave aside the gun control measures, as you're all apt to be reading a great deal about them these days; and, finally, I leave aside the superb presentation on labeling and "smart disclosure" rules, as I have the sense--perhaps wrongly--that we are all aware that many disclosures, mandated as a substitute for regulation on the grounds that people can decide for themselves when adequately informed, do not in fact inform adequately.

I shall instead mention the three options that, for different reasons, gobsmacked me. In each case, I'm relying entirely on data from the presenter's own slides, which I've obtained from the PHLR folks (Thanks, Bethany!)

I present, first, corn masa flour fortification. (This ended up being the crowd's favorite.) Neural tube defects like anencephaly and spina bifida affect about 3000 pregnancies per year. NTD's affect the Hispanic population more profoundly than the rest of the population. This is likely because flour is enriched with folic acid, which helps prevent NTD's, but corn masa flour (widely used in the Hispanic community) is not fortified. Flour fortification has reduced NTD rates by more than a third. A similar rate among Hispanics would prevent 40 NTD's a year. Given the high cost of NTD medical treatment, the public health intervention saves $100 for each $1 spent. And here's the kicker: there is but one major manufacturer of corn masa flour in the US, and this firm has in fact joined public health groups in petitioning the FDA for permission to fortify.

Second, legal reforms to prevent opioid overdose. Did I know that prescription pain-killer overdoses had passed automobile crashes and gun accidents as the number one accidental cause of death in America? No, I did not. 100 a day die from prescription painkiller overdoses--more than die from heroin overdoses and cocaine overdoses combined. There's a drug called Naloxone, which, if administered nasally to someone who's OD'd, will actually interfere with a prescription opioid's effects on the body, and prevent the OD from being fatal. Ambulances and first-responders carry it, but physicians are reluctant to co-prescribe it to people to whom they prescribe pain-killers. This is mainly because the Naloxone is apt to be administered to their patient by someone with whom they don't have a doctor-patient relationship (a relative, or bystander). Docs worry about liability for prescribing a drug to X which is mainly to be administered by not-X. But of course, isn't that how epi-pens are used? Maybe law could be used to create a standard of care that involves co-prescribing the emergency cure with the problematic pain-killers. Next, bystanders often fail to call 911 because they fear arrest. The solution here is a relatively simple, narrow, legal grant of immunity to people who telephone first-responders from the scenes of drug overdoses. Turns out that police--who, after all, have a lot of depressing experience in finding the dead bodies of prescription drug overdosers--don't even mind granting that limited sort of immunity. They'd rather let a few druggies get away than pick up another body. Me, too.

And third, putting decals on cars whose teenaged drivers are subject to various license restrictions, such as not having any non-family members in the car. As the father of a 15 year old, I like this idea. Yes, it makes your car into a police target. That's, um, the idea. Your kid knows s/he's a police target, and caution (or at least obedience to the license-restriction regulations) ensues. Some folks worry that predators will use the decals to make their search for vulnerable teens easier, but really, how hard is it for a predator to look at the driver? And predators, unlike cops enforcing license-restriction rules, aren't picky about the driver's exact age. Here's the main punchline, though: New Jersey put the decals on, and 1600 crashes per year were prevented. Driving is apt to be the most dangerous thing one's teen will ever do, and the decal law helps cops clamp down on teens who evade the sensible rules. In New Jersey, graduated driver's license enforcement rose by 14% after the decals went on. That means, teens who were breaking the rules by driving with their friends in the car were cited, and teens who were driving after dark were cited. As a dad, I'm all in favor.

So: fortify that corn flour! Co-prescribe that antidote! Label those teens! And save lives.