CodeBlueBlog

Terri Schiavo and Stem Cell Research

A commentor, BladeDoc, left these two posts concerning my Terri Schiavo pieces:

The vast majority of ethical debate (and by this I mean debate about ethics not...you get it) about enteral and parenteral supplemental nutrition has come down on the side of it being solely one of the myriad possible medical interventions, no different than a ventilator or antibiotics. Your horrified statement could equally be made about any of those interventions. For example "The Florida Supreme Court has decided that it is OK for Floridians to suffocate someone to death. This is hard to understand." or "The Florida Supreme Court has decided that it is OK for Floridians to let someone die of an infection . This is hard to understand." If you believe that Ms. Schiavo would not want to live like she is now (as did the court that heard the case) then how can you ethically continue to treat her against her perceived wishes? In abbreviated med. ethics jargon "autonomy trumps beneficence." Just because Terry is unable to resist unwanted medical care doesn't mean you have the right to force it on her. Of course if you don't believe in withdrawal of medical support under any circumstances or if you don't believe that Ms. Schiavo wouldn't want to live like this than all of the above is moot.

And:

I also just re-read the entry and I have to say that this paragraph "It is a common practice in medicine to always treat certain conditions in terminal patients -- even those who have signed a DNR ("Do Not Resucitate") order; For example, we will not allow DNR patients to suffer sepsis, and antimicrobial therapy is used." is basically true but inaccurate. DNR is what it stands for -- if the heart stops, don't try to bring it back BUT it is NOT comfort care only. A DNR patient gets EVERY advantage of modern medicine right up until the heart stops and then nothing else. This is ABSOLUTELY not the same thing as withdrawing support on a terminal patient. It is routine in every ICU in the country that when a patient/family requests withdrawal of support (i.e. off the ventilator, stop pressors, etc.) the antibiotics stop. Sometimes it's decided that no escalation of therapy be instituted -- continue everything but don't add anything. It is flatly untrue that antibiotics never get withdrawn. To reiterate, it is unethical and ILLEGAL (assault) to treat anyone against their wishes. That's why no one forces (adult) Christian Scientists into the hospital or makes Jehova's witnesses receive blood transfusions even if they're going to die without one. If a patient or their legal representative refuses a therapy (ANY therapy) you cannot institute it or continue it. Tube feedings (like Ms. Schiavo) are ethically no different -- although emotionally they are.

This is my response:

First, according to the AMA:

"DNR orders only preclude resuscitative efforts in the event of cardiopulmonary arrest and should not influence other therapeutic interventions that may be appropriate for the patient."

Why did they issue this guideline? Because, at the time, the original debate was centered around hopelessly ill and/or terminal patients (where it should have stayed). Granted, the concept has been outrageously expanded since then, but my efforts were to draw attention to this intent.

Second,

Terri Schiavo did not have a living will or any other document which would indicate her desire to die in her current situation. As stated in the Patterico blog:

Ms. Schiavo left no written expression of her wishes, and her own family does not recall her saying anything about the issue. The evidence of her alleged desire to die consists entirely of hearsay testimony from Mr. Schiavo, his brother, and his sister-in-law, concerning statements they say Ms. Schiavo made in casual conversation.

Finally,

It is my belief that withdrawing food and water is quite different from pacing someone's heart and aerating one's lungs artificially; however, that is not the ethical issue that concerns me most in this case; it is the removal of food and water from a living person who is not terminal (any more than you or me). This has GOT to bother a physician. That is my problem. It really bothers me.

Apparently Terri Sciavo expressed her "desire" not to be kept alive, in front of her husband, during a television show about Karen Quinlan.

What if she had seen a show about stem cell research showing the regeneration of neural tissue? Do you think she might have said "Gee, if I weren't suffering, and there is research like that out there...maybe staying alive peacefully on food and water might not be such a bad idea?"

LET'S CALL A SPADE A SPADE...A SNAPPING TURTLE

Malpractice reform is all over the net, especially in the medical blogosphere. I've stated some of my views before. Recently, in a piece regarding John Edwards.

Kevin, M.D. quotes an article regarding the upcoming collision between trial lawyers and physicians, and RangelMD did his usual thorough job.

DB's Medical Rants says a lot about the issue, and is preternaturally patient with his lawyer letterwriters, carrying on discussions and debates that he clearly dominates in without being overweeing.

One new iteration I'd like to add to the ongoing and ever-intensifying melee is a neologism. I think we should call a spade a spade and give the tort lawyers/attorneys/litigators/esquires a name that better pigeonholes those who choose to channel fetuses. I propose torter. You know, like tort lawyer and snapping turtle all rolled into one.
I mean, we call Anesthesiologists gas passers and radiologists rads...I think TORTERS fits the bill. Ever see one in the street and try to pick it up? You're trying to escort it to safety, and it quickly clamps its crushing beak on your finger and in an instant your digit is fractured and macerated.

Starving Terri Schiavo II

There were interesting and informative articles written about the Schiavo case all across the blogosphere this weekend.

Over at Patterico's Pontifications you can learn a lot from the articles on this search page, including elaboration of the idea that Jeb Bush's intervention was analagous to offering clemency to a condemned man.

Xlrq and calblog offer more; and, Media Culpa has started a thread for ideas on how to save Terri.

As an intern at Memorial Sloan Kettering Hospital, twenty years ago, I dealt with many hopelessly terminal patients, many of whom were suffering terribly. One concept that the attending physicians made us understand -- without variability -- was that the object of all our therapeutic decisions, at this point in a patient's life, was to relieve suffering and make the patients comfortable.

We would never have imagined taking out a feeding tube, and it certainly was not in our realm of possible conceptions to take out the feeding tube of a patient who is neither terminal nor suffering.

The concept of intervening to create comfort and peace in one's terminal days, aided by a serious, responsible and moral caregiver has evolved -- or transmogrified--into proactive solutions to problems of long-term care, moderated by an overriding judicial system.

We are at a point of medical and cultural significance.

It would be interesting to hear more physicians weigh in.

Starving Terri Schiavo

The Florida Supreme Court has decided that it is OK for Floridians to starve and dehydrate someone to death. This is hard to understand. RangelMD posts that Ms. Schiavo is in a persistent vegetative state with no hope of recovery and that she should be thought of as a "terminal" patient. He also avers that this case is being made a spectacle by "conservative 'right to life' forces".

These deflections miss the essence of this case, which is that we are allowing someone to be starved to death. Someone who otherwise would not die. We are not allowing her death we are actuating it. There is a big difference.

This is not a patient with widespread metastatic disease or terminal refractory, untreatable illness. This is someone who will continue to live unless we starve and dehydrate her.

It is a common practice in medicine to always treat certain conditions in terminal patients -- even those who have signed a DNR ("Do Not Resucitate") order; For example, we will not allow DNR patients to suffer sepsis, and antimicrobial therapy is used.

How then can we not feed someone? Do we really want to be starving patients? Is there not a difference between making someone comfortable during the ravages of a fatal incurable disease, and taking away food and water?

Insofar as Ms. Schiavo's mental capacities, no matter how much reduced they are (from what standard?), it is perilous to use this argument as a rationale for starving and dehydrating her. It is not a far leap from Terry Schiavo to someone who is severely retarded or demented. Who would want the task of having to draw those lines in and around humanity?

Many have adduced as evidence supporting starvation, that in her mental state, Ms. Schiavo could not possibly suffer physically or mentally from this act.

Then she cannot possibly suffer physically or mentally from its absence.

Will we, as a civilization, be able to make the same claim?

Tort Report: John Edwards' Cash Cow Must Die

Do you know how lawyers like John Edwards choose their malpractice cases? It goes something like this: A patient thinks that he has been harmed or was given substandard care. He writes a letter to a malpractice attorney stating the case.

The attorney decides whether or not it is worthwhile to pursue the case. Worthwhile = amount of money that can possibly be won.

Malpractice attorneys claim that their actions PROTECT patients.

Yet those attorneys decide, almost universally, which cases merit attention based on the possible monetary awards that can be garned, regardless of the merits of the case or whether or not there is actual malpractice involved. Truth is, the biggest awards are doled out in cases that are neither black nor white (so jurors will not be swayed by facts but by emotional appeals such as "channeling" fetuses); or, in cases where the emotional appeal of the defendent is such that it will outweigh the facts.

Unless true medical malpractice fortuitously intersects with the attorney's assessment of the possible $$ rewards of the case, this "system" of patient protection never gets involved in the case.

This "system" is neither efficient at uncovering malpractice, nor does it provide consistent, proven methods of remediation other than cash payments to the defendent and lawyer.

Worse, the manifold ways this ineffective "patient protection system" increases health care costs are intolerable in a time when citizens are getting ready to hand over health care to government rather than foot the bill themselves.

Liability lawyers have been effective in preserving their cash cow partly by tendentious statistics and studies that pretend to prove that their services don't actually raise health care costs.

Well, now, experience is proving them wrong. Texas is showing conclusively that caps on noneconomic damages work.

A process whose purpose is to protect patients and weed out bad medical practice cannot have, as it's major selection crterion, how much money a lawyer can extort from an insurance company or wheedle from a jury.

We can only hope that history will eventually show that this cow was slaughtered in Texas.

BREAST MRI: THE GENIE IN THE BOTTLE

MRI's are better than mammography at finding breast cancer. In a recent study of high risk women, of 22 breast cancers detected, 17 were found by MRI, but only 8 were found by conventional mammography.

For the physicians and scientists out there, MRI's sensitivity was 77% compared to 36% for mammography in this particular cohort.

This study was done with women who are at substantially higher risk (those with BRCA1 and 2), but everyone in the field of breast MRI KNOWS that MRI is more sensitive than mammography across the board. Period.

So why don't we just use screening MRI instead of mammography? Well, there are good reasons. MRI is expensive, and it finds a lot of things that AREN'T cancer and that would lead to biopsies. Besides, it is hard enough to get mass screening done with plain film mammography...getting every woman in every year for a high-field, contrast-enhanced bilateral MRI of the breasts is a mind-boggling proposition...

Further, MRI of the breast costs $800-$1000, whereas mammography runs about $125.00-$150.00.

Finally, all the data are not yet in. Before we initiate massive screening programs that cost tens of millions of dollars every year, we need to know conclusively that screening with MRI would translate into a decrease in breast cancer mortality.

(But you know what...we didn't wait for similar statistical and epidemiological clearance before recommending yearly plain film mammography!)

I'm not saying that we should begin advocating mass screening MRI's for breast cancer; however, I do believe that every single woman who is having a mammogram should understand that there is a more sensitive examination out there.

And then THAT WOMAN should decide if her resources are well spent on an MRI of the breast, given the risk-reward ratio, given the incomplete data, given the state-of-the-art, and given the possibilities of a false-positive result.

There is VERY LITTLE WAY for a woman to make this decision under the current insurance system; and there would be NO WAY AT ALL to choose this option (or any option) under a nationalized (or single payer, or Canadian) type health care system.

The genie in the bottle is not MRI, it's choice.

If we opt for more government control, more Kerry-Clinton like solutions, we will have less control over our health care decisions.

If we embrace Medical Savings Accounts, we will have a say.

Then a woman can look at these issues, evaluate these data and say: I CHOOSE TO HAVE SCREENING BREAST MRI EVERY YEAR.

WE DEMAND TO KNOW: WHAT WILL KERRY DO ABOUT THE AUTOMOBILE CRISIS?

Has John Kerry said just what he intends to do about the AUTOMOBILE CRISIS in America? I haven't heard him mention it.

After all, automobile insurance is too expensive. It isn't universally available. There are too many uninsured. Migrant workers and illegal aliens are not covered. Automobile insurance companies are ruthless in their screening of applicants and their application of benefits.

Auto insurance doesn't cover TUNE-UPS or GAS-UPS! That's absurd! How can we ask people to pay out-of-pocket for costs related to this essential item of living?

But it isn't just insurance causing this AUTOMOBILE CRISIS. Cars themselves are deadly. I mean, true, they get us where we need to go 99.999% of the time, and they do it in comfort and style and with cool stereo music and air conditioning...but...do you know how frequently they break down?? And how expensive they are to repair?? AND AUTOMOBILES are the leading cause of death for people ages 1 to 33 and caused 43,000 deaths in 2001 alone!

We all need cars to live a decent life without fear in America.

The insurance system is inefficient. Predatory. Broken. Automobiles cost too much and are too expensive to keep up and repair. AUTOMOBILES KILL 40,000 AMERICANS EVERY YEAR!

What is the solution to the automobile crisis?

WE NEED THE GOVERNMENT TO IMMEDIATELY NATIONALIZE FORD AND GM

Does that make sense to you? Then YOU agree with Kerry and Clinton and the rest of the logically-impaired promulagators of nationalized health care.

WHICH ONE OF YOU WILL BE FIRST ON LINE FOR THE GOVERNMENT-BUILT CAR?

A DEFINING CRISIS

Health care is in crisis. Is there anyone who doubts this?

JOHN KERRY SAYS SO.

He said: Bush has no plan to address the health care crisis

HILLARY CLINTON SAYS SO. She has long claimed "crisis" and did so again at the Democratic convention when she said of Kerry:

And he will solve a health care crisis for our people, not ignore it

Politicians state that there is a crisis and this becomes fact.

The public quickly moves beyond any argument over whether or not there is actually a crisis and the entire focus becomes FIXING the stated crisis.

Well, I say we need to back-up and discuss definitions. Because Hillary and John are wrong. There is no health care crisis in America.

Merrian-Webster defines health care as:

health care also health·care (h lth kâr ) n.

Function: noun
: efforts made to maintain or restore health especially by trained and licensed professionals -- usually hyphenated when used attributively

There is no crisis in health care. Hillary insofar as admitted this this past weekend when she PRAISED doctors and science for saving her endeared husband's heart from certain catastrophe.

So if there is no crisis in health care, as health care is defined by Merriam Webster and as Hillary and Chelsea so ardently emoted yesterday, then

WHAT IS ALL THE DEBATE ABOUT?

BILL CLINTON'S CHEATIN' HEART BYPASS

This will be Bill Clinton's stopped heart next week.

The former president has checked into Columbia Presbyterian Hospital in Manhattan for elective bypass surgery next week.

It's a good thing for Mr. Clinton that his wife's zany health care reform measure failed in the early nineties, because if we had moved to a single payer system -- where everyone is equal and treated equally by Big Doctor -- Bill Clinton would have to wait for his elective bypass. If the vaunted Canadian system is any measure of this delightful "unanticipated consequence" of nationalized health care, Clinton would have to wait about 14 weeks for surgery after seeing his GP, or about 6 weeks after seeing a specialist. And if Clinton's McDonalized coronary arteries gave out before then? Too bad. That's the acceptable price he pays for the mass delivery of vitiated care to everyone under the single payer strategy.

Oh, and he could also forget about taking his results of years of bad dieting and lack of exercise to one of the most prestigious heart hospitals in the world. Rather, he could have stayed at a local hospital in Westchester -- where he lives.

But that would never happen, even with a nationalized health care system. Why?

Because the truth is that Brahmin like the Clintons and Kerrys and Kennedys will never have to wait -- even if they manage to stuff national health care down our pedestrian throats. As a part of the anointed, they never need suffer the consequences of their socialistic actions. They always move to the front of the line and beat the system they create. It is only their constituency and the vast unwashed who are forced to endure the long lines, poor service, and degraded product brought about by such forward thinking legislation. That's one way these socialized systems are able to survive. We all know that if a politician or his family is inconvenienced or hurt by some social phenomenon there quickly is legislation on the agenda to cure that horrible problem.

For now, maybe Mr. Clinton -- while sitting in his private suite in a prestigious hospital waiting for his expedited elective surgery-- can reflect just for one second on what it means to have a choice: Being able to choose maintains quality and service.

Otherwise we'll all be having our bypasses at the medical equivalent of the post office.