Wednesday, September 24, 2008

Social Activists vs. Ben and Jerry's?

I agree with Peta that there is scant evidence that consuming cow's milk is necessary to sustain a healthy life-style (so long as you get your calcium elsewhere).

However, the Peta folks are off their rockers if they believe that human strangers' milk is a "safer" alternative to bovine strangers' milk, and ought to be used in Ben and Jerry's Ice Cream. BSE notwithstanding, humans are immune to most pathogens (as in Johnes Disease, Bovine Enzootic Leucosis, Bovine Virus Diarrhea) that primarily use farm animals as hosts. No matter how much we try to emphasize our differences between one another, humans have very similar immune systems. Therefore, we are much more susceptible to catching anthroponotic, rather than zoonotic infections (While HIV can be transmitted to nursing newborns, it is somewhat, but not definitively, unlikely to be transmitted through drinking human milk that has already been collected).
Additionally, for bovine diseases that can be passed to humans, it is considerably easier to control infections that erupt in populations of cattle, rather than humans, who don't have a friendly farmer to supervise, track, and test them in herds (although I suppose that such actions are what Peta objects to most, in the first place).

Additionally, if people think that the hormones they inject cows with are bad, are they really ready to ingest some of the medications transferred to breast milk, such as Phenobarbitone (anti-convulsant), Dothiepin (anti-depressant), Promethazine (anti-histamine), Doxycycline (antibiotic), and a myriad of recreational drugs?

I don't know about the rest of you ice cream enthusiasts, but I don't want my Cherry Garcia to require a visit to Quest Diagnostics before it makes it to my freezer.

Tuesday, September 23, 2008

Know-Nothing Pundit With Plenty to Grouch About

I can't claim to understand much about the whole bailout hullabaloo, but I certainly possess some imprecisely aimed anger toward some mysterious shadowy villain (all I know is that he is a banker by day, insurance broker in the afternoon, and congressman in the dead of night).

We regular, old, Americans are just left rubbernecking at all the chaos to patch the cracking beam that apparently suspends our entire earth, and runs only from Wall Street to the Beltway.

While this bailout may at least mean that my patients and I will be less likely to experience the nuisances of a newly-impossible-to-implement national health care plan (unless congress gets a bit of Havana fever, figuring "we've gone this far already..."), I have a feeling that this bailout business is bad for our country overall.

Yes, my knowledge of economics is rudimentary, but it's also my future three-thousand-something-plus dollars that will be used for those Damn Yankees' latest shenanigans, so I insist that even the ignorant be entitled to ask questions:

If fresh capital is necessary to resuscitate and revitalize these companies, why can't we provide be loans, which must be paid back, once the companies get back on their feet? If these businesses are so valuable, why isn't anybody, anybody (China? Bueller?) else willing to buy them, except for our government? If the companies are worthwhile enough to be "saved," why aren't they worthwhile enough to be bought? Surely someone poking around the coal mine has noticed these elusive diamonds in the rough? I've always assumed that if no one wants to buy something, that means that the something isn't actually worth anything.

Many Americans once thought they had some assets/pensions/employment in these companies, and will surely be very, very devastated to find out that, subjective Bayesians be damned, seven years of plenty doesn't imply seven more. Many might end up losing a lot of money. I say, fine, let's bail some of these people out. What I don't understand is, if the government must redistribute income, why not just:
1) Put the $100 billion on layaway,
2) Figure out who ends up the poorest after this big melt-down, and
3) then hand out the cash?
4) Re-assess the situation and see if more is needed.
5) Repeat

Why spend the money now, before we've even identified who needs it most? Last I checked, the heads of companies didn't apply for jobs at any welfare agency, so we shouldn't give the money to them to dole out. Why not knock on the doors of the Food Stamp Program and Department of Labor, hand them a few billions, along with the memo, "Expect busy day tomorrow." We'd still be helping the potential victims of the predicted meltdown, just distributing the money to those who need it, when they need it.

While most people recognize that sending good money after bad doesn't actually help "save" anything, some are conjuring up psychological explanations about why we must bailout these companies. They talk about an capital freeze that will stem from lack of "confidence" or "faith" in the market. I tend to believe businesses are generally judged based on their monetary value, rather than psychological or religious value. But in case I'm wrong, why don't we hire Dr. Phil and the Pope to ease our troubles, rather than Henry Paulson? We are constantly being told that this bailout must happen quickly, lest our country be destroyed, and all the skeptics be turned into pillars of salt. At least Pope Benedict can then intercede on all our behalves.

Monday, September 22, 2008

Today in Medical School: A Chat Between Two Representatives of the Obama Campaign

Or at least that's what the health care policy debate felt like.

My school invited E. Richard Brown Ph.D., Director of the UCLA Center for Health Policy Research and Senior advisor to the Obama campaign to debate Dr. Donald Kurth, M.D. Chief of Addiction Medicine at the Loma Linda University Behavioral Medicine Center, Mayor of Rancho Cucamonga, and Chair of the Health Care policy committee for the McCain campaign.

I don't know which speaker did more to advance Obama's ideas for increased government involvement in medicine. For those who argue that competence in running a campaign is more significant than a candidate's actual policy proposals, then today's spectacle might solidify such people's support for Obama. Let me caveat that I am a hard-core free-marketer, who believes that McCain's health care plan is actually one of the highlights of his candidacy (had he also promised to bring our soldiers home from Iraq, and had eased up on some social issues, I would have been writing this from his campaign volunteer headquarters).

Dr. Kurth seems like a kind gentleman, who cares for his patients, and supports his political positions because he believes they will improve patients' lives. Nevertheless, he presented McCain's plan by reading off the McCain/Palin brochures that had already been left on our auditorium seats. He spent a few too many minutes talking about his own professional degrees and experience. His only argument against government-controlled health care consisted of a personal story working for the U.K. National Health Service thirty years ago, in which his advisor, a surgeon, didn't make lots of money, and some patient he met had to wait a few years before receiving his hip replacement. When asked questions about the McCain plan, he admitted that he didn't know the details, and instead continuously repeated the same emotional mantra "Do you want the government to get between you and your patients?" That line was the answer to about seven different questions (admittedly challenging, sometimes antagonistic, questions- this is Obama Country, after all).

After Dr. Kurth's very short presentation, Dr. Brown barely had to open his mouth to "win" the debate. But he went much further than even describing Obama's plan. All parts of McCain's plan that Dr. Kurth was unfamiliar with were explained in detail by Dr. Brown, before he summarily refuted them with facts and figures, rather than personal experiences. It was like watching Lennox Lewis take on my old Tae-Bo instructor.

Without a real sparring partner, Mr. Brown talked for about a half-hour, and got away with quoting every questionnable statistic, and its intepretation as fact (i.e. "48 million Americans don't have health insurance," without a mention that this includes illegal immigrants, whose health costs ought not to be subsidized any more than those of any given world citizen- and I even support immigration reform). If free-marketers believe that socialists advance their causes through romantic emotionalism, rather than rational data, they would be disappointed to see who are currently carrying each movement's torch. Here was one guy, the so-called "Marxist" who came across as professional, fluent in policy, and well-prepared. Then there was the other guy, the "Capitalist," who seemed to have a verbal tic in his constant repetition of "I believe in the free market" and described, very generally, that he has some problems dealing with the government bureaucracies in his medical practice.

(As an unrelated aside, my audience question to Dr. Brown was as follows: "There are many controversial cultural issues in medicine, including abortion rights, medical futility, and transgender surgery. How do you feel that the existence of a National Health Insurance Exchange might affect the debate regarding cultural issues? More specifically, in the case of medical futility, who would decide when the plug is pulled? The patient's family or the people footing the bill, who may not have made the patient's decision for themselves?" The line to pitch questions to the Obama representative consisted of: Me. The line to ask questions of the McCain consisted of at least 6 upset people).

After the "debate," we discussed the two health care plans in our classroom. Considering the overwhelming support for Obama in my medical school, as well as the poor performance of the McCain representative, I have to give my fellow students a lot of credit. They asked a lot of the important questions that made me realize that there are knee-jerk liberals, and liberals who ask and consider probing, relevant questions. In our classroom discussion, some people queried, "How would these plans be paid for?" "How would we insure that costs don't go up if there are coverage mandates? How do we prevent increased premiums for healthy people (or a healthy person exodus from costly plans), once insurers are required to disregard "pre-existing conditions"? Would illegal immigrants be eligible for free care? If not, who would be left to pay for their medical expenses?) Despite my constant feeling of being a political minority in my medical school, I do admire and respect my classmates. It's just a shame that the one opportunity for many people to hear a cogent argument on behalf of the free market was was so devastatingly wasted.

Saturday, September 20, 2008

Anesthesia Irreverence

Courtesy of the Laryngospams, a singing group of CRNAs (Certified Registered Nurse Anesthetists):

And if you mastered the breathing part, here's for the more advanced:

Pelvic Examination Training

First, a word of warning to all the women out there:
If you see a male second-year medical student with a speculum in his hand, drop everything and run.

Luckily, our victims this week were vinyl dummies, not-unlike the kind sold to lonely middle-aged men who visit unsafely-searched websites. These unenthusiastic volunteers, come with a set of interchangeable parts (Cervix with endocervical polyp! Cervix with neoplasia!, Pregnant 10 week uterus! Two adnexal masses!). The sneaky doctors mix up Eva's (as she is always called) internal organs, so we can test our abilities to palpate and identify her various pathologies. Eva does not charge by the hour, but her $597 fee ought to be returned if you diagnose her correctly.

I've noticed a bit of a difference in how we are taught to perform the male versus female pelvic exams. The gynecologist gets up, and with a soft, sympathetic voice, talks about how she carefully drapes the patient, and eases her into the examination, by first placing her hand on the patient's knee and then thigh (she recommended that all doctors do this, to comfort the patient, but I insist that any male doctor who cares about retaining his license ignore that advice), before performing the exam. All anatomy is referred to by the most professional sounding jargon we have in our medical toolbox. "Sensitivity" and "comfort" are each mentioned about 12 times during her presentation.

In contrast, the urologist is crass and bawdy, talking about his own and others' mastrubation habits, and joking about how Los Angeles doctors, many of them Jews, are clueless about the fact that patients can get severely edematous retracted foreskin, if the patients fail to put it back where they found it. He seems to imply that the most important thing is to reduce the "unmanly" factor as much as possible when you position the patient during the prostate exam ("I call this the last position any male wants to get into"). He described an inguinal hernia as "Dude, where'd my penis go?"

Of course, we are taught to interact respectfully and professionally with all of our patients. But I do wonder if there is a silent understanding among doctors, that some men prefer to have their discomforts dispelled by bluntness and Adam-Carolla-style humor, while women often prefer to be treated with sensitivity. Of course, the above observations are gross generalizations, but it's the impression I've gotten so far, watching the style and mannerisms of the gynecologists versus the urologists. During the pertinent rotations, I'll report back on whether I still find this to be the case, or if generic "doctor-speak" is employed for all.

Wednesday, September 17, 2008

Another Powerpoint Exhumed!

I gave this presentation last week for medical students in the training session for "Community Impact," a program in we teach about topics such as "Drugs and Alcohol," "Dating Violence" and "Contraception" to kids in Juvenile Hall. My specific topic addressed job opportunities available for teens, as part of the "Decision Making" module. So unless you happen not to know a kid in the L.A. area who just finished Juvy and is now looking for a job in the neighborhood, this widely-relevant presentation is for you!
Job Tips For Teens
View SlideShare presentation or Upload your own.

Spared from the Powerpoint Graveyard: LGBT Health Care

Each week, we have a class called "Professionalism in Medicine (PPM)," in which a group presents on a topic concerning medical ethics, health care politics, or community-specific medical needs. We also invite relevant speakers to talk about their experiences navigating our vast American medical morass. For example, this week's topic was "Patients with Disabilities." After watching excerpts from "Murderball," we listened to a man with quadriplegia speak to us about, after his accident, what the doctors did that he perceived as helpful or unhelpful (Helpful: Hooking him up with other patients in a similar situation. Also helpful: Very frank and specific talk about the potential prospects and exact methods for having sex. Unhelpful: Doing anything for the patient that he could do by himself).

When the topic was alternative medicine, our school invited naturopaths, homeopaths, chiropractors, acupuncturists, reflexologists, etc. to speak to us about their practices (Regardless of what any one feels about alternative medicine, it's important for allopathic doctors to be familiar with the practioners' interventions, and to learn how to work with patients and their other health care providers in a productive manners). Next week, representatives from the McCain and Obama campaigns will speak to our class about the candidates' various health policy proposals.

About two weeks ago, my friend and I gave a presentation concerning LGBT health care to our "Professionalism Practice in Medicine (PPM)" class. I addressed basic definitions about sexuality and gender, as well as some pertinent legal issues, while my friend focused on specific health care needs and disparities of the LGBT community. We ended up meshing both our powerpoints, but, because I am not sure if she wants her work advertised on the internet, I'm only posting my portion.

Although I enjoyed giving the presentation, as I waded through some of the many websites, books, and papers dedicated to "LGBT Health Care," I've been pondering some of the pluses an minuses of codifying such a group. In general, I maintain some reservations about addressing "Group-specific Health Care," including "LGBT Health Care." While I didn't mention such concerns in our talk, I wanted to go over some of them here:

1) Higher/Lower Pre-test Probabilities. Lesbian women are at increased risk for breast cancer. If we know and talk about elevated risk of gay men and lesbians for contracting certain diseases, we will be more vigilant in screening them for such diseases.

2) Unique Mental Health Issues/Addiction. Homosexuality correlates with higher rates of depression, drug addiction, and other mental illnesses. LGBT people often face disapproving families, unaccepting religious groups, or simply their own struggles with their sexuality. Knowing this, the doctor can better engage with the patient, talk to her about her troubles, and screen her treatment with anti-depressants or referral to psychotherapy.

3) Fostering Rapport. Most gay or lesbian patients do not suffer from depression or addiction. However, for some people, if the doctor doesn't address or seem to know anything about their sexuality, they may wonder what the doctor would really think about them, if she knew, and cause some distance between the doctor and her patients.

4) Unique Legal Challenges. It's important for doctors to know the laws regarding the authority of a domestic partner over end-of-life decisions, guardianship of a partner's children, extent of insurance coverage from her partner's plan, etc.

5) Possible Extra Need for Privacy. The health records of the "happily-married" senator, who is on the dl, may need to be stored in a seperate place, not to be seen by the rest of the medical staff.

6) Early Identification of Community-Specific Pandemics. Last year, an article addressing a spike in methicillin-resistant staph. aureus among gay men with HIV caused a wind-storm. Many gay activists denounced the article, especially after some Right-wing Christian groups categorized its findings as evidence of strike upon modern Gomorrah. However, fundamentalism and feelings aside, if early identification of group-concentrated pandemics can help us thumb tag each exposure on a public-health map, we can perhaps nip the outbreak in the bud a bit faster.

7) Intersex and Transgender Health: Unique Needs. It's probably a good idea for doctors about sex-reassignment surgery or MTF hormone therapy, considering that these are common procedures for trans-sexuals. Additionally, the controversy involving intersex children have prodded many doctors to take a more "let's wait and see what gender the kid ends up preferring before we chop anything off" for hermaphrodites, and to resist performing immediate surgery on the neonate.


1) Group Identity. Some people simply do not want to be classified in some group called "LGBT." They want to just be seen as "Angela" or "Bill," and as having personal health needs.

2) Sexual Fluidity. If we accept Kinsey's notion that the binary view of sexual identity (gay vs. straight) inadequately describes American's multi-layered and diffuse pattern of sexual preferences and experiences throughout life, the border between "LGBT" and "Straight" starts to become somewhat artificial.

3) Discounting Potential Health Risks. Perhaps too much emphasis on someone's sexuality can bias against certain diagnoses. While lesbian women are less likely to contract HPV, some evidence suggests that, if a lesbian develops cervical cancer, it is often diagnosed at a later age. There are many possible reasons for this (lack of medical access, the fact that lesbians don't need birth control and, therefore, see the gynecologist less often). However, some studies also suggest that lesbians are simply are not offered a pap smear at the same rate as are straight women, presumably because doctors see their risk as being low.

4) Avoiding Social Bias. When we focus on LGBT health, we run the risk of calling, for example, HIV, a "gay man's disease." Other than the fact that this could lead to all kinds "told you sos" from the peanut-gallery, some straight people may behave more recklessly, assuming that they aren't at risk for such illnesses.

5) Focusing on Risk Factors. Lesbian women are at increased risk of breast cancer, but this has nothing to do with the gender of their sex partners. Nulliparous women (women who've never given birth), as well as obese women (lesbians are more likely to be obese) are at increased risk for breast cancer. Perhaps it is most useful to focus on individuals' specific causative risk factors, which may or not be correlated with their sexual identities.

So, now that you've heard my spiel questioning the category of "LGBT Health Care," please please enjoy my presentation on that very topic:
Lgbt Health Adina Only
View SlideShare presentation or Upload your own.

Tuesday, September 16, 2008

Fully Informed Patient

The New York Times has an article explaining how patients, once they've left the emergency department, are often confused about their conditions and recommended routine follow-ups. Patients' understanding of their illnesses and how to properly maintain and monitor their medications and health status are essential. However, I believe it is a mistake to insist that such knowledge derive from ER staff. In fact, the more we do to enhance this idea that a fully-informed patient should walk out the ED, the more we re-enforce misuse of the emergency department, which can have dangerous repercussions on overall patient morbidity and mortality.

The emergency room should be primarily used for emergencies, rather than health maintenance, and should NEVER serve as the patient's final stop in the body-fixin' assembly line. At an urgent setting, patients should be stabilized and cleared from any immediate threat to their health. Ideally, they should also know what to do when they return home. However, within the very same week, if not the next day, patients should follow up with a visit to the INTERNIST or FAMILY DOCTOR (there are many free clinics in L.A. where patients can see primary care physicians). There, patients can and should inquire more about their condition and general health, to achieve all of the information that they need to maintain control over their day-to-day well-being.

What people must understand is that there are trade-offs to everything. In medical wonderland of the future, people will leave from every medical situation fully informed. I, for one, subscribe to the old-school style of doctoring of partnering with the patient, in which it usually takes no less than an hour to discuss her medical conditions. Talking with patients is one of the reasons why I'm still committed to this messed-up profession.

However, it is impossible for an ER to provide the patient with the information he needs. Attempting to do so might give the patient a false sense that he requires no follow-up with a general practitioner. However the most serious consequence is that, If ER doctors, nurses, PAs, or even the cafeteria lady who happens to be standing by, spent more time fully explaining people's conditions, then the 8+ hour average wait time at my hospital's ED would inevitably be further extended. This could translate to addressing fewer time-sensitive emergencies.
While we may see the patient with the severe MVA or gun shot wounds first, the patient sitting quietly who had severe chest chest pain a few hours ago, and now seems fine, will have to sit around a bit longer. If such patient had an MI, every minute is more muscle tissue lost.

Life is about trade-offs. As we think about the additional enhancements we can theoretically implement in ER, let's be very careful about what our patients might have to give up in return.

Monday, September 15, 2008

I'm Rich?

Above, is an (admittedly poor quality) picture I took of a heaping pile of many billions of Zimbabwean dollars. Rejoice Ngwenya, a very brave writer and activist from Zimbabwe, had set up the table to impress upon the attendees of Cato University the extent of his country's stratospheric inflation. Such a pile doesn't even buy a loaf of bread, and the people of Zimbabwe either try to flee to Botswana or South Africa, identify something to exchange for food in the black market, or simply starve.

Well today, Mugabe the Terrible finally signed an accord with the opposition leader, Morgan Tsvangirai, allowing them to control roughly equal parts of the government. Perhaps soon the $750,000 bank note that I swiped (today's value: 0.000000939496 USD) from the pile will be worth more of what it advertises! All joking aside, as much as Tsvangirai obviously defeated Mugabe in the election, this power-share concession is a promising opportunity to reduce the tyrranical oppression, let alone disease and starvation afflicting the Zimbabwean people.

She Wants a Job? Well, She's a Victim, and Should Work For Fellow Victims Instead

This basically sums up (admittedly, with editorialization) the suggestions made by Lawrence Gostin, Law Professor at Georgetown, in an article titled "International Migration and Recruitment of Nurses: Human Rights and Global Justice"in the April 16, 2008 issue of Journal of American Medical Association (Subscription required. Yes, I catch up late).

Due to our country's nursing shortage, U.S. hospitals actively recruit and sponsor worker's visas for nurses who were trained in foreign countries. This represents a considerable opportunity for many health care workers to improve their family's lives, but also a problem for developing countries that face their own (significantly larger) nursing shortages. While Mr. Gostin recognizes freedom of migration as a human right, he volunteers such nurses as martyrs for the ailing people in their own countries, which require "the human resources necessary to ensure the right to health care for their populations."

If maintaining human resources is a required component of respecting civil rights, who logically must be impinging on these rights by reducing the human resource pool? Presumably, workers themselves, who, while choosing to improve their own lives, neglected their "responsibility to contribute to the public's health, safety, and welfare of their home country." Of course, the U.S. is not left off the hook either for this "global injustice." Our country's hospital administrators and bureaucrats are admonished for informing people about better opportunities, as "advocates for global health call active recruitment in low-income countries a crime."

Such criminal behavior does not stem from providing too many perks or incentives to to workers to stay in this country, offers that would certainly aggravate global nursing disparities. Rather, Mr. Gostin, somewhat incoherently, believes that the U.S. contributes to the problem by victimising the nurses, "luring them with misleading promises, and threatening [them] with deportation if they break their contract." Is it a crime to sponsor people to stay here or a crime to prevent them from staying too long?

Nursing is probably one of the most grueling, difficult jobs available, and it is probably hardest for foreign workers, who besides dealing with language or cultural barriers, tend to work for the poorest hospitals. However, if abuse is as pervasive as Mr. Gostin suggests (before he advocates for state laws to prevent discrimination, poor and unsafe working conditions, unequal pay and treatment, as well as other perceived injustices), why would it constitute such a threat to send such workers home? Shouldn't it be a blessing to release people from their shackles? And if people are so desperate to stay here, despite all of the employment regulations that hospitals seem to violate, wouldn't increasing incomes and improving working conditions for nurses only discourage them from returning home, which is Mr. Gostin's goal? After all, Mr. Gostin believes that we have a responsibility to place incentives for workers to "stay at home, or return home after visiting abroad."

Mr. Gostin somehow believes that, if we increased benefits, we'd snatch up fewer foreign workers, who, now flooded with cash, would desire to return home. I'm skeptical. Guarantees of minimum salaries and expansions of benefits would only provide a new flood of nurses, astute enough to apply for entry to this country, whether or not we banned "active recruitment."

Mr. Gostin's fundamental problem is that he struggles to portray both the workers, as well as the people they "neglect," as victims. He also attempts to condemn the United States for offering too many opportunities, as well as too few (or at least for not long enough). Presumably, every inconsistency could be untangled if we assume that all of the hospitals systematically break promises or contracts made at time of recruitment. However, even if we did assume ubiquitous deceptive and exploitative behavior, this would not explain why most workers strongly prefer to stay and work in the U.S.

By designating aggressors and victims for a hodge-podge of perceived, and often contradictory, indiscretions, Mr. Gostin hinders advancement of his central goal, which is presumably to increase the number of health care workers in developing countries. Additionally, so long as people "owe" services, simply because they possess skills and others have needs, whenever such people forge their own paths, choose their own options, and advance their own values, they, according to Mr. Gostin's reasoning, inevitably contribute to violating others' human rights.

Sunday, September 14, 2008

Pharm Free

Among medical students today, the most fashionable accessory is designed by neither Prada nor Fendi. It is that canvas tote thing, similar to the one your grandma brings to the supermarket. Except this one features duct tape plastered over some undecipherable slogan, that once said "Plavix" or "Celebrex." On the duct tape is often written "Pharm Rx." By wearing this bag, the medical student signals to the world that, despite being a future member of a stuffy aristocratic profession, the student is radical, independent, and averse to shilling for Big Pharma.

The problem is, by covering up the name of the pharmaceutical company, the future doctor does his patients and colleagues a disservice. The purpose of "Pharm Free" campaigns is to insure that the physician's recommendations are never inappropriately influenced by bribery, which could harm the unsuspecting patient. However, when a company showers a doctor with gifts, and he discloses this fact to those around him, he at least allows them to form their own opinions about the reliability of the doctor's subsequent professional recommendations. By accepting perks, but refusing to give up the names of his bank-rollers, and by concealing their names on his complementary tote bag, the doc's actions ought to be considered, in the minds of Pharm-Freers, as plain old corruption.

Saturday, September 13, 2008

Insurance-Promoted Suicide?

At Covert Rationing, "Dr. Rich" bemoans physician-assisted suicide and euthanasia. He presents a letter sent by an insurance provider, which advertises to its subscribers that such interventions would be, what Dr. Rich terms, "compassionately offered and cheerfully paid for." Dr. Rich questions the motivations of such promotions as follows:

"When reducing costs and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy."

Dr. Rich is correct that decisions concerning euthanasia are not necessarily driven by pure motivations, a concept especially apparent when "patient choice" is championed inconsistently. However, it does not follow that nobody would recommend physician-assisted suicide or euthanasia if it didn't save a bureaucrat some money (as Dr. Rich seems to suggest), or that it is inherently unethical.

Let's assume that sometimes euthanasia is appropriate, which we'll define as meaning that it is the intervention that the patient would have really, truly wanted, had we been able to glean his choice, unsullied by the pressures of other stake-holders. If the insurance company advocates for euthanasia, its recommendation could be categorized as follows:

1) Inappropriate, but saves company some money (Company as devil)
2) Inappropriate, and the company loses money (Company as accidental devil)
3) Appropriate, and company loses money (the company as merciful angel of death)
4) Appropriate, but also happens to save company some money (company as possible applicant to become devil, but assigned as merciful angel of death.

In option 4, unlike option 2, the company's interests happen to coincide with the best interests of the patient. Therefore, just as we shouldn't automatically accept a company's recommendation when it has something to gain, we shouldn't automatically reject their recommendation, just because it has something to gain. We need to simply work harder to establish and implement the patient's will.

Ideally, the power of the insurance company's biases would diminish if its contracts delineated, at time of patient enrollment, the extent of coverage provided for life support, at various degrees of brain damage. If it were plainly written, "we do not provide continuing treatment for patients in a persistent vegetative state, when such a diagnosis is determined by three separate physicians," then conscientious objectors would choose to take their money elsewhere. They could also pay a higher premium for the expectation that their organs would be kept alive. It would then be up to the hospital and patient's family, when the time comes, whether or not to keep the patient on life support, and who must pay for it. The insurance company ideally decides what medical procedures it covers, not whether such procedures are medically justified.

To me, such issues underscore the potential dangers of implementing universal health care. We could potentially be left with a system, in which everyone foots the bill for ventilators that most would have refused for themselves. Alternatively, we could inappropriately end up pulling the plug on people, as administrators ration away all costly end-of-life care medical in favor of services perceived as more urgent. Inevitably, we'd draw the line at a place that runs counter to the wishes of most patients, who have complex values and needs.

This is not just an economic issue, but a potentially significant instigator of the Culture Wars. As much as social conservatives hate taxes and abortion, what aggravates them most is that their taxes are complicit in providing abortions. Most people have an easier time minding their own business when they aren't footing the bill for other people's perceived unsavory activities. Once the government starts making decisions about the extent of coverage for euthanasia, transgender surgery, abortion, and alternative medicine, every one will find his own beef. Hence, economic issues will increase every one's aggravation concerning social issues.

What about people who can't afford health care? Should they be the ones whose plugs are automatically pulled, because they lack the resources to choose the more expensive option? Ideally, people who care about such people's wishes, concerning this issues, would help fund the life-saving measures of such terminally ill patients. It is a difficult matter that the patients wouldn't get to choose their fates, and yet also a difficult matter that an unwilling sponsor can't choose the fate of his taxes, which may have otherwise gone to someone else's cancer treatment. Yet, one way to solve this problem would be to implement government health care policies in which patients are simply given cash to purchase insurance and treatments. After ranking their own list of medical priorities, patients would choose among private plans. They may choose to buy a plan with comprehensive ventilator coverage, or a plan that comes with extra chiropractic visits.

Admittedly, taxpayers would still indirectly pay for people's health care decisions. But the contrast is analagous to the theoretical (and likely rare) person who spends his welfare dollars on prostitution and drugs, rather than the a person who obtains such goods and services from a benevolent single payer, who compensates pimps and dealers directly. In the latter, the government, on behalf of the taxpayers and society overall, chooses to pay for objectionable services. In the former, we simply gave the person some cash, to spend under his own discretion and autonomy. The choices he makes are ultimately his own.(As an aside- for those who believe that I am calling doctors pimps, please note that I am making an analogy, rather than a comparison. Although doctors as drug-dealers is not as off-base).

When it comes to euthanasia, and all other controversial medical issues, the more we allow people to make their own decisions, the less we have to worry about competing profit motives and our personal moral conundrums.

Friday, September 12, 2008

Pregnancy Pact

Remember the national scandal a few months ago about the "pregnancy pact" among some teenage girls in Small Town, Massachusetts, which led to cries for increased access to birth control/implementation of abstinence-only education/mandatory curfews for teenagers/increased parental prosecution/development of self-esteem curricula/stricter TV and video game ratings/Focus on the Family take-over of government/ People for the American Way take-over instead?

What those girls did was foolish, but I took on the Judge Kozinski-inspired viewpoint of “The parties are hereby advised to chill.” (An exception goes to the actual girls and their parents; Future daughter, if you're reading this, don't think that kind of irresponsible behavior is tolerated in this house).

At the Tijuana clinic I volunteered at in Colonia Obrera, there were five girls, ranging in ages 13-16,who plopped down on the bench in the makeshift shed-cum-medical office, and gigglingly requested some pregnancy tests. Three of the five turned out to be pregnant, while the other two were so genuinely disappointed by their negative results, that they asked if there weren't some "prueba otra." What this means to me is that some girls, in many little towns around the world, make "pregnancy pacts" with their friends. The difference is that when it happened in the U.S., it led to double-overtime for Fox News staff, while in TJ it was just another group of girls seen in the clinic before we broke for our lunch of nachos and pink water from the cooler. This demonstrates how startlingly rare these things are in the U.S., and maybe we should celebrate that we're doing something right.

Homeboy Industries

A few weeks ago, Father Greg, founder of Homeboy Industries (a company comprised of former gang members, which runs silk-screening, maintenance, merchandising, and cafe operations around L.A. county) and Treyvon, one such former gang member, came to speak to our medical school class. Father Greg's speech was one of those laugh-and-cry moments (the kind I won't attempt to recount in detail, as literary justice will not be served- but I do recommend that you hear him speak. I warn conservatives that they may have to ignore some angry non-sequiturs directed at Bush Jr.). Treyvon's speech was equally brilliant, and he told his story with a mixture of precise detail, worldly insights, and sage advice. One story he recounted addressed the day he sat in his car with a friend, when the friend was gunned down by a passer-bye. Random brain tissue was left splattered on Treyvon's lap. The friend wasn't in a gang. The hit was meant for Treyvon.

In front of the class, Treyvon asked me directly what I imagined gang members were like. I gave some stammering, incoherent answer. What was I to say?- "Um, According to 'The Wire,' people like D'angelo and Wallace seem to have some heart." The truth is, I know nothing about gang-members, what motivates most of them to join crime groups, or how they feel about what they do. Treyvon's journey involved a drug-addicted mom, an absent dad, a crappy school, little hope for the future, and more convincing images of neighborly brotherhood through gangs than of Ivy league lawns or frat parties. Treyvon now mentors hundreds of kids, is studying to become and audio engineer, and is all-around great guy. He also stated that most gang members, like him, joined the groups because they were desperate to be loved. Mind you, this is a tough-talking 23-year-old with plenty of swagger and bling. Very few med school neurotics would admit that they want to feel loved, although I'd say that it's pretty much a universal human sentiment. Treyvon is a brave guy.

Thursday, September 11, 2008

Narcotics Unbound

Cato Unbound features a typically fascinating essay, this time about creating a "Culture of Responsible Drug Use." Earth and Fire Erowid effectively argue that the notion of responsible drug use has as much relevance now as it does for an idealized post-prohibitionist future. Today, many, many Americans practice self-control regarding psychoactive substances, which are relatively easy for otherwise law-abiding citizens to obtain, especially if one includes legal "drugs," such as alcohol or caffeine. And no matter the endless shuffle of kids charged with "posession," who languish in the Juvenile Hall next to my school, or the bluster and spectacle of high-profile raids on marijuana dispensaries that cater to cancer patients. These shining examples of the DEA's good work (as well as its upcoming "Target America Campaign" which first takes aim at Los Angeles in October), do nothing to temper the reality that even the most socially isolated individual can gain access to the Internet and access to drugs, practically within same Charter Bundle Package. Simply typing in "Amsterdam" and "marijuana," allows one to quickly identify some foreign cannabis collective. The consumer can then immediately mail some cash in a inconspicuous birthday card labelled "To Grandma Adelheit," while waiting around for Ganesha's Dream to arrive.

In 2007, 42% of 12th-graders admitted to having used marijuana, according to a NIH study. When we speak about legalizing responsible drug use, high schoolers are not even our intended demographic. Yet most of these burgeoning adults somehow learn to consider the pros and cons of illicit substances, and end up figuring out how to monitor, or eventually terminate, their intake.

The Erowids' essay, however, never fully touches on the concept of addiction, slowly diminishing self-control, and the subsequent ramifications concerning personal autonomy. Most libertarians would argue that people have the right to decide whether or not use drugs, and to accept the responsibility for drugs' potential risks. But what if, after that first hit, the brain down-grades its stock of pleasure receptors? And if, just a few hits later, the desperate remaining receptors recognize the brain's waning neurohormone activity, and subsequently beg for a spare neurotransmitter to please, please come their way? With enough inconsolable pleading, the person may feel no other option than to "shut up" the receptors by acquiescing to their demands, and taking yet another hit.

Numerous experiments have shown that mice, once introduced to cocaine, will scamper toward the mesolimbic reward impostor instead of food, even if such behavior leads to the mice suffering from starvation and increasingly dangerous electric shocks. Without its first dabble in drugs, the mouse's addiction would have forever remained an unknown potential- a series of dormant nucleotides scripted in his genetic code, never to be unleashed by specific transcription factors. Certain mice, as well as people, may fall on the extreme right of the "genetic susceptibility to addiction" bell curve. However, one is never actually dedicated to a substance, just a chemical compound like any other, before the substance has been properly introduced to the brain.

Thus, what if obtaining that first high constitutes an "original sin" which slowly progresses to a nightmarish path of diminishing self-control, yet increasing physiological and social consequences? Are addicts simply suffering the effects of a single choice made that first day? The frontal cortex, or decision-making part of the brain, eventually starts to play virtually no role in the junkie's mind regarding drug use. This helps explain the abysmal long-term recovery rates for users, even those who attended fancy treatment centers. When it is neurologically proven that someone has lost self-control over addiction, should they still retain the personal autonomy associated with drug use?

Of course, these issues do not apply to certain drugs. It seems unconvincing that marijuana is addictive altogether. Additionally, the activity of the "partial agonist" group of opioids eventually approaches an asymptotic limit in its potential activity. By inhabiting the receptors of more powerful drugs, partial agonists prevent the development of increasing tolerance. It is difficult to determine the merits of banning such substances.

Perhaps better research, as well as screening for genetic risk factors of addiction will enhance people's abilities to become responsible decision-makers regarding narcotics. We know that D1-receptor deficient "knockout mice" refuse to partake in cocaine's pleasures, a fact that may have useful applications for people with a family history of addiction.

Despite the limitations of personal autonomy in reference to drug addiction, it does not necessarily follow that the government has the right to prevent potential addictions by banning controlled substances, nor that prohibiting such substances actually reduces addiction rates. Most advocates of minimum central authority believe that, in general, government failures stem from its relative inferiority compared to an aggregate of rational actors, producing, consuming, and consorting in ways that reflect individuals' personal priorities and rational self-interests.

However, in the case of addictive drugs, it is very difficult to determine when rational self-interest ends, and a drug's potentially freakish domination begins. While this does not mean that the government should intervene, it does impose on libertarians the concept that villains can indeed be of our own making. Whenever we reduce the impositions of government, we add to the moral burden and responsibility to be beared and voluntarily fulfilled by caring family and friends.

Straw Man

David Brooks touts the findings of modern neuropsychology as evidence that Goldwater conservatism is incompatible with human beings' natural inclination to establish interdependent relationships and collaborative institutions.

But who ever said that we shouldn't form social networks? Libertarians simply believe that such networks should be strictly VOLUNTARY. The "communities" created by government are always mandatory, which inspires more discord than camaraderie. It isn't that libertarians and libertarian Republicans do not believe in charity or community. It's simply that we believe that we should choose the charities and communities with which to associate.
Trust me, many of we libertarians have close friends, from all political spectra and walks of life, whom we care for deeply. We don't need the government to set up play-dates.

Wednesday, September 3, 2008

The Scarlet VP

I’m not usually one to yell "sexism" at every turn, but I do hate hypocrisy. When many "progressive" people clamor for Sarah Palin to step down, go home, and take care of her family, such helpful advisors undescore a prevalent bias that a woman's career goals are pretty insignificant. They feel that Palin, as a woman, should easily sacrifice a once-in-a-lifetime opportunity the moment there's an issue involving her soon-to-be-adult daughter.

Even if Palin were pro-choice or pro-comprehensive sex ed (as I am), her daughter still could have gotten pregnant. Earth to fellow sex ed instructors (I teach about contraception and STDs in Juvenile Hall): Providing comprehensive education does not entail actually showing up to the bedroom. You can't control what teenagers do. All of those excuses about her conservative political positions justifying criticism of her family's problems are red herrings.

Why would any "liberal" think that Palin's first responsibility should be to "spare" her family, rather than worry about her career goals? I ask all men out there: Do your careers have such little importance, that you would sacrifice everything you’ve worked for, the moment your 17-year old made a mistake? No, you’d probably work longer hours to make more money, so you could help support the child. And you’d become as successful as possible, to become a role model for your child and grandchild.

In college, I used to see many women wearing shirts announcing “I had an abortion.” It seems that having had an abortion is a source of pride for some people. However, apparently being pregnant is so unbearably shameful, such a huge scarlet letter, that people are saying that Palin should step down simply to avoid “exposing” her daughter or thrusting her into the limelight. Well, there would be no limelight if people stopped acting like pregnancy was the greatest possible scourge for a young woman (And don’t tell me that your mentioning these things are justified because it simply reflects what conservatives believe. You either uphold your principles or you don’t. And you don't take out any potential conservative hypocracies on a 17-year-old, who may be pro-choice, for all you know).

Palin’s son is in the army. Although, this decision is extraordinarily honorable, it involves enormous danger and risk. Yet, we are more “worried” about the young woman who will have a baby in a safe environment than the other kid who is potentially one convoy trip away from getting killed. Do we only feel the need to "protect" girls, rather than boys? Or is it just that this has nothing to do with women’s welfare, and everything to do with pregnancy taboos?

Update 2.12.09 It feels strange reading this post, so many months later. Soon after posting it, I became thoroughly underwhelmed with Governor Palin, as did many others. Was I right to avoid judging her so quickly, and to give her a chance, or should have I been clued in to her lack of qualifications much earlier? Not sure.