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.

Friday Frovolity, Cancerous Obese Vegetarian Edition

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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.

Nuffield on "Public Ethics"

I always enjoy and benefit from reading the reports of the Nuffield Council on Bioethics. Its latest on Emerging Biotechnologies is no exception. I hope to have more to say about the substance of this report in future posts, but for now I want to single out one of its features for questioning. The report makes a great point of the importance of thinking about emerging biotechnologies from what it calls a "public ethics" perspective. The public, the Council urges, has various important interests at stake in the regulation of emerging biotechnologies: the impact they'll have "on a public scale;" the public resources invested in them; the "significance attached to living things;" and their potential to change our lives, and to benefit some at the expense of others. We need to hold these public interests in mind when doing our ethical analyses. We can't leave private or scientific interests in charge. The Council articulates three "values" of public ethics (equity, solidarity and sustainability) and five "procedural virtues" of public ethics (Openness and inclusion,Accountability, Public reasoning, Candour, Enablement, and Caution).

When I first saw this, I thought immediately of Rawls's "Idea of Public Reason." But it turns out there's nothing so subtle or interesting here. Where Rawls was thinking about the kinds of reasons that could properly be mobilized in a public debate (general principles of equity, for example, rather than private religious convictions), the Council's talk of "public ethics" seems to be asserting the claims of public and collective interests against those of private interests. Their insistence on public ethics is not an insistence on a way to conduct ethical debate in public, but rather an insistence that ethical debate should be dominated by public rather than private interests. Normally, regulation is bargained for by those with focused interests in that regulation's structure. Those who would benefit or be burdened by a proposed regulation organize themselves politically in order to shape it. Folks tend not to mobilize and organize to shape regulations that will benefit them or burden them only in a diffuse, small way. (That's why the US Clean Air Act poses a classic mystery for Poli Sci. Its burdens--costs of compliance--were concentrated on a highly-motivated few, while its benefits--slightly cleaner air--were diffuse and uncertain. Yet it passed.) The Council here seems to be arguing, "Don't let the focused interests of industry run away with nanotech or synthetic biology; regulatory framing should instead be dominated by consideration of the admittedly diffuse and disorganized interests of the general public--because, diffuse as they may be, they weigh more in the end than the focused and organized interests of the small numbers of people concerned with developing new biotech."

On this reading, the Nuffield Council's promotion of "public ethics" is a quiet sort of attack on the normative Interest Group Theory of Politics.

Friday Frivolity: Hair of the Lime that Bit You Edition

The Liverpool Care Pathway Kerfuffle

The British press has been hurling around various accusations about the use and misuse of the Liverpool Care Pathway for the Dying Patient ("LCP") for a couple of years now. The LCP is a UK care pathway covering palliative care and nursing options for patients at the end of life. It includes prompts for management of a wide range of end-of-life symptoms; crucially for the debate, it provides for cessation of artificial nutrition and hydration for some patients. The latest round of adverse coverage is largely based on findings of an audit undertaken by the LCP's developer; the audit found that in 44% percent of cases in which a decision was made to place a patient on the LCP, there was no record of a discussion with the patient about that decision; and that one-third of patients' families were never given an informational leaflet describing the LCP. Additionally, there are accusations that hospitals are putting people on the LCP who shouldn't be, perhaps in order to secure financial rewards that flow to facilities that reach targets for LCP use. These allegations, combined with earlier alarmist claims that the LCP was being used to "euthanize" scores of thousands of patients who weren't dying, resulted last month in the government's announcing the launch of an independent investigation into the use of the LCP.

Since that announcement, though, an additional accusation has been leveled in the Daily Mail (which has been pressing the LCP issue all along). Citing this anonymous article from BMJ about withdrawing feeding from newborns, the Daily Mail claimed that babies were being put on the LCP. The trouble is, the BMJ article was written by a physician not based in the UK, and not using the LCP. Of course, that didn't prevent the Daily Mail piece from being picked up here in the states by, for example, Wesley Smith, whose sensitive treatment of the subject, entitled "Dehydrating Disabled Babies in UK Hospitals" ran in the National Review Online. "This is what happens when a country allows bureaucrats to control healthcare," he intoned--and then drew the "parallel" to Obamacare. Similar discussion could be found on numerous right-wing websites. Will any of those sites revise their comments now that their foundation in the Daily Mail piece has been exposed as fact-free? I'm not holding my breath.

At this point, I hope the independent investigation is thorough and that it makes serious recommendations for addressing all of these concerns. A tough review with real suggestions for training and reform might well save the LCP, and the LCP is well worth saving. The protocol has won plaudits in palliative care journals, was well reviewed in the Royal College of Physicians original National Care of the Dying audit, has garnered the support of palliative care nurses, and undoubtedly eases the deaths of many tens of thousands annually. But there seems also to be little doubt that it has sometimes been carelessly implemented, or implemented with insufficient discussion and explanation.

One suggestion--indeed, a plea--for anyone who wants to comment on the issue, though: Read the actual pathway. That will have the salutary effect of enabling you to distinguish problems that result from following it from those that result from not following it.

Medicare coverage litigation--Jimmo v. Sebelius

I'm a few days late covering this vitally important settlement of litigation between patient groups and Medicare, but I thought I'd give a small taste of what it's really about.

My mother-in-law passed away in January of ALS (Lou Gherig's disease). That disease, among other things, gradually eliminates your ability to control your limbs, while leaving you with full sensation. In other words (to take an easily understood example), you can be lying in your bed, wishing you could roll over because your arm is in an uncomfortable position, but not be able to roll yourself over. All night.

Physical therapy, you can easily imagine, was a great relief to my mother-in-law. It's a huge benefit to have your body moved around by someone else, in the ways you'd like to move it yourself, if you could: stretching, twisting, opening up. Even just 20 minutes of externally-supplied mobility each day goes a long way toward making up for the immobility the ALS patient faces the other 23 hours and 40 minutes of each day.

But the Massachusetts entity that holds the contract to administer Medicare (along with very many other state contract-holders) decided that Medicare should not pay for my mother-in-law's physical therapy, because it did not stand any chance of curing her.

At some level, of course, one can understand a cost-controlling rule that says, "We're not paying for things that don't work." It was such a rule that Massachusetts's and other states's intermediaries were attempting to follow. But it's simply false to think that anything that doesn't cure you doesn't "work." Think of physical therapy, or nursing attention, for example: many who are chronically or terminally ill can benefit from those kinds of interventions, even if they hold out no prospect for cure.

And that's what the government agreed to in its settlement of Jimmo v. Sebelius. Manuals that guide the decision-making of contractors who administer Medicare at the state level will no longer permit denials of payment to therapies simply on grounds that they don't cure. They'll now explicitly permit payments for treatments that help maintain the patient's current condition or that prevent further deterioration. Mind you, the holding isn't as generous as a rule that might permit payment for every treatment that keeps a patient comfortable, or that reduces a patient's suffering; but it's a big improvement over the "we only pay for cures" position that a number of Medicare intermediaries had been taking.

My mother-in-law offered testimony in this case. Luckily, during the pendency of the case, my father-in-law had sufficient private funds to pay for the therapy she needed to keep herself comfortable during the months of her ALS decline. But she always knew that the Massachusetts Medicare intermediary's position just wasn't right; that it couldn't be the case that national health insurance wouldn't pay for care that met people's basic human needs, even if it wouldn't cure them.

So now, after this settlement, Medicare will pay for those needs. That will certainly drive up the cost of Medicare. But I don't mind. I don't mind paying the extra taxes necessary to ensure that patients, like my mother-in-law, who are paralyzed with ALS, will be able to get their legs manipulated, or their arms massaged, if that's what will bring them comfort.

Mary would be very pleased that her lawsuit was settled favorably to patients. She and her husband didn't need the money; to them, it was a question of principle. But this settlement brings real relief to thousands of people who have no other means of paying for the care they need.

It's a big deal. I offer now a toast, to our now-departed litigant, Mary: You won. You're gone, and can't enjoy the victory, but that doesn't matter. You weren't fundamentally fighting this battle for yourself. And many thousands will benefit from the lawsuit you supported.