| | | |
| |
The rather bizarre furore over 'presumed consent' for organ donations no doubt still rages, but I haven't gone looking for it so I cannot be sure what idiocies it has reached. I don't intend to add fuel to the fire but instead to illuminate one aspect - the moral and philosophical case for donation - by considering a variation on a common thought experiment.
Imagine you have a button in front of you. If you press that button, someone, somewhere will receive life saving medical treatment. It won't cost you anything and your own health will be unaffected. You will not know who they are, what is wrong with them or anything at all about them andfd they nothing of you, other than that some anonymous person has helped them. Your only contact is that button.
Do you press it? I can't imagine any (rational) circumstance in which the answer would be no. So why don't we do it? I say we don't do it, because unlike most thought experiments, this one is realistic. That button exists - at least metaphorically. It is a Donor Card.
| | | |
| |
Via Norm comes this bizarre example of bureacratic nonsense.
A year ago, researchers at Johns Hopkins University published the results of a program that instituted in nearly every intensive care unit in Michigan a simple five-step checklist designed to prevent certain hospital infections. It reminds doctors to make sure, for example, that before putting large intravenous lines into patients, they actually wash their hands and don a sterile gown and gloves.
The results were stunning. Within three months, the rate of bloodstream infections from these I.V. lines fell by two-thirds. The average I.C.U. cut its infection rate from 4 percent to zero. Over 18 months, the program saved more than 1,500 lives and nearly $200 million.
Yet this past month, the Office for Human Research Protections shut the program down. The agency issued notice to the researchers and the Michigan Health and Hospital Association that, by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations. Johns Hopkins had to halt not only the program in Michigan but also its plans to extend it to hospitals in New Jersey and Rhode Island.
| | | |
| |
There is a view of art that places it at the top of human endeavours, represented I suppose by people like Michaelangelo, Da Vinci, Van Gogh, Rembrandt. However the existence of such elevated work does not invalidate art produced by us lesser mortals.
Oscar Wilde is supposed to have said, in response to a question about why America had such high levels of violence, “because you have such awful wallpaper”. This seemingly flippant response masks an essential truth, enumerated recently on TV by Stephen Fry, that we seem to be the only species able to make the place uglier by our efforts. Not everything we do of course – I think the sublime qualities of the English countryside must surely count as one of the greatest artistic achievements of all time.
Nevertheless, the environment we create for ourselves is often impoverished and at worst downright ugly - even unhealthy. We know as a race we can do better. The challenge is to create the conditions in which that can happen. Artists surely have a part to play and while a 21st Century Michaelangelo would be nice we can't rely on that so it will depend on all of us to raise our sights - at least occasionally - from the cashbook to the world around us.
| | | |
| |
From Time Goes By
Chad Boult, who is a professor of geriatrics at Johns Hopkins University, was asked recently what can be done to ensure that there are enough geriatricians as the elder population grows in coming years. "'Nothing,' he said. ‘It’s too late.’ Creating geriatricians takes years,” continues writer Atul Gawande, “and we already have far too few.
| | | |
| |
Quite a few of my recent posts – all tagged I think ‘Reclaim the
State’ – have been based around the idea of personal choice and self-ownership
and the degree to which these ideas should be pre-eminent. Some claim I know –
and not just individualist anarchists - that individual rights do indeed trump
all others. Where conflict arises between individuals this argument seems to me
to rely on the principle that defence of those rights by all means necessary is
legitimate – ultimately therefore on armed force. I’ll perhaps come back to
that another time.
Most however, me included, accept that some limitations on
individual actions are essential, while continuing to disagree on what those
limitations might be and their extent. For example, if someone has a highly
contagious and potentially fatal disease like smallpox, most would think it a
very severe view of liberty not to accept that the infected person should be
isolated from society to prevent that disease spreading. The loss of liberty
for this person is surely essential for the avoidance of a much greater evil,
namely the spread of that disease to many others and does them no lasting harm.
Even so, this is still a complex issue. While isolation is a
fairly neutral term, it still means imprisonment; moreover imprisonment for
reasons beyond the control of the infected person. While there is precedent, this must always
be a difficult decision. It raises serious questions about the balance between
the collective rights of people in society against those of individuals. In the
case of Mary Mallon –
otherwise known as ‘Typhoid Mary’, she knowingly placed others at risk, even
though she had been repeatedly been told of the threat she posed to others. She
was kept in a hospital away from society for three years until she promised not
to work with food. She broke that promise and was confined again, this time
until her death. It is known that she was responsible for the deaths of at
least 3 people, possibly as many as 50.
In Mary’s case, transmission of the disease did not occur except
through poor hygiene in the handling of food. It is possible to imagine however
much more virulent diseases where an asymptomatic carrier is at large. As a
thought experiment imagine a highly virulent, perhaps genetically engineered
disease which somehow turns 1% of those infected into symptom less carriers.
These people show no symptoms but if allowed to wander around would infect the
rest of the population and spread the disease further. Assuming some test is
available to identify them, should they be confined? Perhaps more to the point
how do we administer the tests required? Blood tests for example are invasive
and in themselves require consent. Is it legitimate therefore to require
everyone to submit to a blood test in order to identify the 1% who are
carriers?
What happens if the percentage is not 1% but 10%, 20%, 30% or 40%?
Is there a threshold point at which the risk to society at large, perhaps to
humanity itself makes such an intrusion acceptable? What happens if these
people choose not to be tested or confined? Can the state use deadly force to
protect others? Some of the implications of this are dealt with in a science
fiction context in Greg Bear’s book ‘Darwin’s
Radio’, but the potential threat posed by Bird Flu reminds us that there
are real dangers.
Immunisation takes us into even more difficult territory. Unlike
confinement, immunisation depends on an ‘invasion’ of the person. It also
depends on ‘herd immunity'
to be fully effective. In other words when the proportion of vaccinated people
in a population exceeds a given percentage, the spread of the disease is
effectively stopped - to the benefit of the unvaccinated as much as the
vaccinated. This percentage depends on the disease and the vaccine, but 90% is
not uncommon. Failure to take up immunisation thus places at risk not just that
individual, but also every other un-immunised person – including people who may
be allergic, too young or too old.
The classic recent example of this was the debate over MMR, where
because of fears about a relationship between the vaccination and autism,
vaccination levels in some areas of the country have fallen well below the herd
immunity level, with consequent increase in infection rates.
Even with high vaccination levels those affected by measles are
not evenly
distributed.
Where vaccination is widely
practiced, as in the United States since 1962, measles has continued to occur
in poorly immunized subgroups that are characterized by low educational level
and economic status, very young age, or religious beliefs forbidding acceptance
of vaccine. Ultimate success of a systematic immunization program requires knowledge
of distribution of susceptibles by age and subgroup and maximal effort to
reduce the concentration of susceptibles throughout the community rather than
aiming to reach any specific proportion of the overall population.
The vulnerable sub-groups described above presumably do not choose
to be vulnerable and the low take up of MMR vaccine in these groups is not in
general related to concerns about side effects. By contrast parents who do choose
not to immunise thier children are doing so because of specific fears about the MMR vaccine.
In doing so they are effectively deciding that the risk
of adverse effects to their child from the combined injection outweighs the
risk of contracting Measles, Mumps or Rubella including the increase in
that risk as a result of the decline in herd immunity.
If these fears are unfounded, as is almost certainly the case,
then these calculations are erroneous and are increasing the general risk of
infection for all children. Setting those particular concerns aside for the
moment however, it must be recognised that there will still be some cases of an adverse
reaction. In those circumstances would it be legitimate to make vaccination
compulsory?
It seems to me that for low levels of adverse reaction the case
can be made but it is by no means clear-cut. The number of children aged 10 and
under in the UK in 2001 was slightly over 8m. Assuming for the moment an
adverse reaction rate of 1 in 100,000 children, this would mean 80 children
would suffer across the country as a result of the MMR injection if every one
of the 8m were given the vaccine. An outbreak of measles triggered by the
vaccination rate falling below the herd immunity level would almost certainly
lead to many more than that suffering serious illness including blindness.
While I don’t think the science of herd immunity is disputed, I
suspect that parents withholding their children from MMR are underestimating
the risk of contracting the diseases against which it protects, are probably
not factoring in at all the increased risk due to loss of herd immunity, and are almost certainly overestimating the risk of adverse reaction to
the vaccine. It is easy to say they are acting irrationally, but the essence of
this sort of decision is not just about risk, but also about where that risk
falls. If they overestimate the risk of an adverse reaction it is a risk
nevertheless that affects their child, while the risk of contracting the
disease is a risk spread across all children. The choice of perspective on the
decision affects the decision itself.
I’m not sure where this leaves my original questions. We appear to
have a situation where individuals acting as rationally as possible in
situations of imperfect knowledge nevertheless produce outcomes that are not
optimal for themselves or for society as a whole. Is this of itself enough justification for compulsion?
| | | |
| |
According to a study cited in New Scientist magazine (11 November 06) at least 4% of all deaths in US hospitals might have been avoided if the patient diagnosis had been right. It seems the figures are higher still in other countries.
While this is an awful lot of deaths, they are not necessarily a sign of negligence or incompetence. Diagnosis is a complex process and it is perhaps more surprising that doctors get it right so often than that they get it wrong. House seems pretty accurate in that respect. There are however few studies of the causes of misdiagnosis. One limited study is interesting in finding that typically it was not just one thing that goes wrong but five or six.
There are few studies of the causes of misdiagnosis. One limited study is interesting in finding that typically it was not just one thing that went wrong but five or six. Whatever the cause, nothing can be done unless the fact of misdiagnosis is identified. This will require more data than is currently available. The only sure way this can be acquired is through autopsies. However the number of hospital autopsies is declining in most countries. In the UK, the fall out from the Alder Hay scandal has been a major factor in causing this decline while similar stories have apparently emerged in Australia and Ireland. Doctors are now much less likely to ask for an autopsy in the first place. Another factor may, as ever, be fear of litigation. This seems most likely to be what is preventing the imposition of a minimum autopsy rate. If on the other hand, doctors keep quiet there is no chance of improvement.
Ideally autopsies should be carried out randomly. In the US there was until 1970 a requirement for a minimum hospital autopsy rate of 20%. The Royal College of Pathologists in the UK proposed a target of 10%, but this was scuppered by Alder Hay.
Setting a target is always going to be difficult. Getting consent for an autopsy can be distressing for medical staff, let alone for relatives. I know – I’ve been on the receiving end.
Coercion is difficult to justify. One should normally be free to act as one desires, subject only to causing no harm to others. Refusing consent for an autopsy does no direct harm, but by preventing potential additions to the body of knowledge of illness or the practice of diagnosis there is a clear if indefinable consequence.
So is a statutory requirement the answer? Perhaps in this case it is – it removes the fear of litigation from the equation and might give relatives some sense that their loved one’s death could at least have some value in the end. It worked for me.
| | | |
| |
A common target for the anti-environmentalists is the alleged ban on DDT and the supposed deaths of millions of people from malaria as a result, usually throwing in hysterical refeences to Rachel Carson's book, Silent Spring and a sprinking of 'environazis'. Tim Lambert has done a good demolition job on this garbage [via Crooked Timber].
(The graph on the left) shows that malaria did skyrocket in India in the 70s. But not because they cut back on DDT spraying because of pressure from environmentalists. The graph shows that they didn’t cut back on DDT, but dramatically increased its use. So how come malaria increased? Well, the increase in DDT use was in agriculture. This caused the insects to become resistant, so they had to use more DDT to get the same effect. This caused more resistance, so even more DDT was used and so on. The end result was that in the areas where DDT was used in agriculture, the mosquitoes became completely resistant and DDT no longer stopped them from spreading malaria, with the disastrous results shown in the graph.
Was this catastrophe predictable? Well, yes. In fact, Rachel Carson warned about it in Silent Spring. If India had followed the example of the United States and banned the agricultural use of DDT and reserved it for public health many millions of cases of malaria would have been prevented. However, India probably could not have afforded the more expensive alternative insecticides to DDT, so this may not have been feasible. But there were other alternatives that would have greatly reduced pesticide use and slowed the development of resistance.
He incidently also does a good job on those rootin' tootin' libertarians who want to turn the world into a series of armed camps because that will reduce crime. (It doesn't, as the his archive clearly shows.)
This is supported by the findings of a recent study of murder rates in the UK by Shaw, Tunstall and Dorling. Despite the apparent rise in murder rates since 1981, for every social group bar one the rate actually fell:
This study analyses demographic and spatial factors that underlie the rise in murder rates seen in Britain between 1981 and 2000 and considers the possible contribution of a public health approach to the understanding of murder. Comparison of murder rates by age group and sex finds that increases occurred only among males aged 5–59 years, and were greatest among males aged 20–24 years. Analysis of the relationship with poverty at the area level, using the Breadline Britain index and deciles based on wards, demonstrates that increases in murder rates were concentrated in the poorest areas. Rates of murder have risen in the same population groups and areas that have experienced increases in suicide and may be associated with worsening social and spatial inequality. (from the abstract)
In other words addressing inequality has real practical, social and economic benefits.
For the time being, you can listen to one of the authors here.
| | | |
| |
Opehlia Benson in excellent rant mode.
Why do people think it's fine for their putative God to wipe out people in wholesale lots but it's not all right for us to make a quick exit? Where is the sense in that? Why are we supposed (and expected) to have such reverence for the cruel sadistic bastard that we have to stick around for purposeless pain on his account? Why don't they make themselves sick, saying things like that? I would really like to know.
| | | |
| |
It isn't unusual to find myself shouting at the radio or TV, but it is usually when some opinionated politician exceeds even my tolerance level but I don't hink I have ever shouted at Woman's Hour before. The occasion was an item about the possible new vaccination against some types of cervical cancer and the idiot on the receiving end was Christina Odone. Listen here as she argues that prepubescent girls should not be given the vaccine because it would encourage them to have sex without fear of the cpnsequences. I thought Professor Margaret Stanley, the other speaker demonstrated remarkable levels of self control.
Odone's egregious twaddle reached new depths I think even for Catholic theologians, comparable only to the way on which the Catholic Church has been spreading nonsense about AIDs in Africa.
| | | |
| |