A number of bioethics twitterers were calling attention to this piece on addiction and philosophy from the New York Times's online Opinionator page. I enjoyed it, but thought that at its core it was more the application of a metaphor drawn from philosophy to the problem of addiction, rather than a philosophical treatment of the problem of addiction. So I googled around for a philosophical treatment of addiction and found this piece by Piers Benn. It is a genuinely philosophical treatment of the issue, but one which fails for lack of familiarity with contemporary addiction science.
In the piece, Benn asks whether addiction is properly termed a disease. (He speaks mostly about alcohol addiction, and so shall I.) Benn entertains and rejects four reasons why we might consider it a disease. The first is people sometimes argue that it would be more humane for us to talk about it that way, and thus to relieve addicts from blame and stigma. But Benn rejects that argument, favoring a "tough love" approach. (In another portion of the essay, he rejects the idea that addicts can't control themselves, essentially by pointing to the fact that some addicts can and do.) The second reason he considers for the disease model is that "the disease model seemingly gains support from genetics;" on this point, he cites a study from 1973 that showed that children of alcoholics, raised by non-alcoholic parents, are more likely to become alcoholic. Benn rejects this on grounds that genetic predispositions to drink don't actually force anyone to drink, and don't keep everyone from quitting. The third justification for the disease model is that addicts often talk about their own experience of powerlessness--inability to quit their habit even though they want to; Benn rejects this as self-deception. Addicts, he implies, aren't powerless, they just think they are. The fourth reason is that ordinary language often describes addiction in terms of irresistible forces and compulsions; Benn recommends that we simply think about addiction differently, as involving powerful forces, but not irresistible ones.
The underlying theme seems to be that addiction can only be a disease if it implies complete lack of control and therefore supplies addicts with a moral excuse for their conduct. If some addicts can control their behavior, then addiction doesn't imply complete lack of control, and therefore isn't a disease, and therefore supplies no moral excuse.
This won't do. First, it implicitly regards "addiction" as uniform, such that the ability of one person to kick an addiction is proof that all others could have done so as well, but for their weakness of will. Second, as Benn comes close to admitting at the close of the essay, the whole essay maps the idea of disease onto an idea of powerlessness which doesn't make sense. Some Type II diabetics can bring their insulin and blood-glucose under control with diet and exercise. Does this imply that the others aren't really sick?
Most unfortunate, though, is the fact that the whole article proceeds without any investigation into the current science of addiction. Scores of studies since 1973 have confirmed genetic predispositions to addiction, not only in humans but also in rats and monkeys. And contemporary brain-scan science has firmly established that the brain's reward-triggers are physically altered by substance use among addicts, in a way that they are not among mere "social users" of the same substances. (These results, too, have been duplicated in other species.) Recent brain-imaging studies have show that addicted alcoholics, unlike social drinkers, drink less for pleasure than for stress-relief; and that alcohol abuse among those with the correct genetic predisposition sensitizes the brains to stressors. This sensitization lasts well after detoxification, both in humans and in other species, and may help explain high rates of relapse. And finally, it's been shown that judgment centers of the brain (in the prefrontal cortex) are physically inhibited by alcohol intake, so that when (as Benn puts it) the tenth drink seems "highly alluring" to the alcoholic, that is not because (as Benn argues) the alcoholic is being akratic, and lacks the resolution to act on his better judgment, but because the portion of the brain which might normally supply better judgment has literally been shut down.
Someone, somewhere, might mount a philosophical argument against the disease model of addiction. But such an argument cannot be based only on armchair reflections about how we use language, about the Greek view of weakness of will, or about whether medicalization of addiction would or would not be kind. It must, also, deal with the science of the last four decades.
Tuesday, January 10, 2012
Monday, January 9, 2012
Chimeric Monkeys, Mice and Stem Cells
Shoukhrat Mitalipov of the Oregon National Primate Research Center has created chimeric rhesus monkeys, each of whose bodies combines tissues with up to six different genetic identities. The chimera creation was part of research which showed that--unlike in the case of mice--chimeras cannot be formed by injecting rhesus embryonic stem cells into blastocysts. Chimera formation was instead achieved by aggregating several four-cell embryos (a result never achieved in mice). The research hints at some important limitations of using mouse embryonic stem cell models to predict experience in primates, including humans.
The Onion has gathered some on-the-street comments on the research, including from Mr. Bobo.
The Onion has gathered some on-the-street comments on the research, including from Mr. Bobo.
Online Advance Directives
Virginia has recently decided to create an advance directives registry which, when it goes live sometime this spring, will permit patients to upload their own living wills. The plan is eventually to integrate the advance directives information into the state's health information exchange, so that physicians will be able to access their patients' documents without needing to know their login information. The hope is that physicians will then be able to act on their patients' previously-expressed wishes without having to locate and contact surrogate decision makers.
Saturday, January 7, 2012
Bioethics Poetry, Emily Dickinson Edition
Death is a Dialogue between
Death is a Dialogue between
The Spirit and the Dust.
"Dissolve" says Death -- The Spirit "Sir
I have another Trust" --
Death doubts it -- Argues from the Ground --
The Spirit turns away
Just laying off for evidence
An Overcoat of Clay.
Emily Dickinson
(Mary M. Scott Morton, RIP)
Death is a Dialogue between
The Spirit and the Dust.
"Dissolve" says Death -- The Spirit "Sir
I have another Trust" --
Death doubts it -- Argues from the Ground --
The Spirit turns away
Just laying off for evidence
An Overcoat of Clay.
Emily Dickinson
(Mary M. Scott Morton, RIP)
86% of Medical Error Goes Unreported
Hospital incident reporting systems were informed of only 14% of errors that harmed Medicare patients, according to this report on a recent survey undertaken by the Department of Health and Human Services Office of Inspector General. Hospital staff didn't perceive 61% of adverse events as reportable. Another 25% were classified as of a type commonly reported, but somehow not reported this time.
Remember what the Institute of Medicine told us, back in 1999, about how we ought to be dealing with medical errors? We're supposed to report them all, in a blame-free atmosphere, in order to gather information that will help us change the systems which give rise to them. The idea was that we'd make more progress by reporting error in this blame-neutral way than by either a) covering the error up or b) blaming error on particular human beings. The basic assumption was that most medical error resulted from flawed systems (training systems, oversight systems, information systems, and so on) which put hospital staff at predictable and preventable risk of making mistakes.
Some progress has been made. But this latest report shows how very far we have to go. A 14% reporting rate is absolutely dreadful, particularly because this is the report-rate for events that actually harmed Medicare patients. The IOM's goal was that not only harmful errors, but also "near-misses"--events that could have harmed patients, but luckily didn't--should be reported.
The Inspector General recommends that the government establish a list of reportable events, so that there's clarity about what needs to be reported and what doesn't; and that CMS (the Medicare agency) cooperate with accrediting bodies like the Joint Commission to establish review of hospital reporting procedures. Accrediting bodies currently tend to concentrate on what's done with reported information, rather than on the accuracy and breadth of the reporting process itself. That clearly needs to change.
Remember what the Institute of Medicine told us, back in 1999, about how we ought to be dealing with medical errors? We're supposed to report them all, in a blame-free atmosphere, in order to gather information that will help us change the systems which give rise to them. The idea was that we'd make more progress by reporting error in this blame-neutral way than by either a) covering the error up or b) blaming error on particular human beings. The basic assumption was that most medical error resulted from flawed systems (training systems, oversight systems, information systems, and so on) which put hospital staff at predictable and preventable risk of making mistakes.
Some progress has been made. But this latest report shows how very far we have to go. A 14% reporting rate is absolutely dreadful, particularly because this is the report-rate for events that actually harmed Medicare patients. The IOM's goal was that not only harmful errors, but also "near-misses"--events that could have harmed patients, but luckily didn't--should be reported.
The Inspector General recommends that the government establish a list of reportable events, so that there's clarity about what needs to be reported and what doesn't; and that CMS (the Medicare agency) cooperate with accrediting bodies like the Joint Commission to establish review of hospital reporting procedures. Accrediting bodies currently tend to concentrate on what's done with reported information, rather than on the accuracy and breadth of the reporting process itself. That clearly needs to change.
Friday, January 6, 2012
Regulation, War, and Face Transplants
These proposed regulations from the US Department of Health and Human Services would subject vascularized composite allographs (VCA) to the rules currently governing solid organ procurement and transplantation. VCA involves transplanting multiple tissue-types as a single functional unit. The highest-profile VCA procedures are face and hand transplants, but VCA procedures around the world have included limb transplants, abdominal wall transplants, finger transplants, and transplants of penises and uteruses. What the procedures have in common is the need for re-vascularization via surgical connection of blood vessels to the transplanted tissue. Bringing these procedures under the existing organ procurement and transplantation rules will rationalize the supply and distribution of transplantable tissue, and permit medical teams to find better matches for their patients.
Recent successes in face-transplantation have captured a great deal of media attention. But another reason for this move is the medical aftermath of the US military presence in Iraq and Afghanistan. More than 1,000 military personnel have lost an arm or a leg in these conflicts; one fifth of those have lost two or more limbs. In the summer of 2010 there were an estimated 200 soldiers who might be eligible for partial or full face transplant, and an additional 50 who could use hand or forearm transplants. The US Departments of Defense and of Veterans Affairs have been leading funders of research on limb and face transplantation. The proposed regulation of VCA is in part aimed at permitting more veterans to get the procedures they need, with the best available material.
Recent successes in face-transplantation have captured a great deal of media attention. But another reason for this move is the medical aftermath of the US military presence in Iraq and Afghanistan. More than 1,000 military personnel have lost an arm or a leg in these conflicts; one fifth of those have lost two or more limbs. In the summer of 2010 there were an estimated 200 soldiers who might be eligible for partial or full face transplant, and an additional 50 who could use hand or forearm transplants. The US Departments of Defense and of Veterans Affairs have been leading funders of research on limb and face transplantation. The proposed regulation of VCA is in part aimed at permitting more veterans to get the procedures they need, with the best available material.
Thursday, January 5, 2012
Hepatitis C Vaccine Success and Chimpanzees
This article from Science Translational Medicine shows excellent results in a phase-1 trial of a new hepatitis C vaccine. This is a huge deal: hepatitis C infects 170 million globally, and causes a great deal of the world's liver damage. It kills more people in the US annually than HIV/AIDS.
The new vaccine was developed using chimpanzees as research subjects. I submit that this is exactly the sort of research for which the IOM's recent report on use of chimps in research left room. But I submit, also, that there aren't many more examples of this sort.
The new vaccine was developed using chimpanzees as research subjects. I submit that this is exactly the sort of research for which the IOM's recent report on use of chimps in research left room. But I submit, also, that there aren't many more examples of this sort.
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