On the deactivation of implantable devices

Tough ethical questions

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There is an interesting thread on Twitter generated by a BBC article relating the case of a British patient who was granted the right to have her pacemaker deactivated.  Dr. Wes Fisher was interviewed in the article.

The question posed is whether this constitutes assisted suicide or not.  Dr. John Mandrola pointed to the position document of the Heart Rhythm Society regarding such cases and seems firm that pacemaker deactivation is not euthanasia.

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Three cheers for the statin war

The days of healthcare utilitarianism are numbered!

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If anyone has any lingering doubts that the promises of evidence-based medicine are quickly evaporating, the recent blog post by Larry Husten on the statin war should quickly dispel them.  Husten gives an excellent account of the latest battle opposing the pro- and the anti- camps.

What happened?

The pro-statinists published a 30-page diatribe in The Lancet.  Statins save lives, they assert.  The evidence is incontrovertible.  Yes, they can have side effects such as muscle pain, no one disputes that.  But drawing attention to those side-effects—as the anti-statinists do—endangers patients who now find a reason to refuse to take the life-saving drugs.  There’s evidence of that happening.

The anti-statinists voiced their position in the BMJ.  Statins cause muscle pain and fatigue, they assert.  The evidence is incontrovertible.  Yes, they can save lives, no one disputes that.  But trumpeting the benefits or down-playing the harm—as the statinists do—prevents patients from partaking in the glorious activity of “shared-decision making.”  There’s evidence of that happening.

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The brave new world of contemporary bioethics

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A few months ago, I tweeted that today’s ethicists sometimes serve the function that sophists used to fulfill in Ancient Greece: to provide moral cover for the powerful.  A “consensus statement” issued last week by a committee of philosophers and bioethicists  brings some pertinence to my comment.

These international scholars–all from prestigious Western institutions–had met in June in Geneva, Switzerland to take up the question of conscientious objection in healthcare.  Here are the first five points of their ten-point statement, published on the Practical Ethics blog of the University of Oxford philosophy department:

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Beauty, chemistry, and natural philosophy

Summer reflections

Molecules? by Jori Samonen, via Flickr.  (CC BY 2.0)
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About a year ago, Theral Timpson interviewed Stanford chemist Carolyn Bertozzi on his Mendelspod podcast.  I only heard the show recently and enjoyed it.  The title caught my attention: “Is the future of biology a return to chemistry?”

Bertozzi made some interesting comments about her field, which she regards as “the central science,” and Timpson probed her about her expectations for the place of chemistry in what is otherwise expected to be “the century of biology.”

The discussion was of interest to me for two reasons.

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The mother of all medical errors

Iatrogenesis in perspective

Healing the sick, fresco by Domenico di Bartolo. Sala del Pellegrinaio (hall of the pilgrim), Hospital Santa Maria della Scala, Siena. Public Domain, via Wikimedia
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A study published a couple of months ago in the BMJ  made headlines for claiming that medical errors are the third leading cause of death.  As expected, the reactions were swift and polarized.

For some, the study confirmed that the self-serving healthcare system is utterly careless about the welfare of patients.  For others, the claim was complete hogwash, based on faulty methodology designed to justify further regulatory oversight.

The two positions are not necessarily mutually exclusive.

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Risk-factor medicine

An industry out of control

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If concepts could get awards, then “risk factor” would surely be a Nobel prize winner.  Barely over 50 years of age, it enjoys such an important place in medicine that I suspect most of us doctors could hardly imagine practicing without it.  Yet, clearly, the concept is not native to our profession nor is its success entirely justified.

A few years ago, on the occasion of the risk factor’s fiftieth anniversary, my colleague Herb Fred and I published an editorial highlighting some of the problem with the use of this concept.  I will summarize here some of those points.

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Risk factors, causes, and the diet-lipid hypothesis

A conversation with a reader about medicine's Ptolemaic epicycles

Photo credit: By by jefras a.k.a Jo?o Est?v?o A. de Freitas. Public Domain,
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I shared with a reader an editorial I co-wrote in 2010 entitled “Risk-Factor Medicine: An Industry Out of Control?” Subsequently we had the following e-mail exchange, which I thought might be of interest to other readers of Alert and Oriented.  I was impressed by Robert’s comments and learned a few things from him and from the links he provided.

On April 29, 2016, Robert wrote:

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Interview on the Wake-Up Call podcast.

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I had the pleasure of being interviewed by Adam Camac and Daniel Laguros, hosts of the Wake-Up Call podcast.  We talked about the history of American healthcare.  The interview was broken down into 2 segmenst.  Here is part 1 and here is part 2.  I highly recommend this podcast.  Adam and Daniel are very good hosts and they have terrific guests, covering a wide range of topics.  You can subscribe on iTunes.

The pharma-fed doctor

And the foundation-fed healthcare journalist

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In his recent article “Feed Me, Pharma,” ProPublica’s Charles Ornstein has been calling attention to studies showing that the prescribing decisions of doctors are linked to the amount of money that drug companies can bestow on them, usually in the form of meals, travel expenses, tuition support to attend courses, and so on.

I find nothing surprising about that, and Ornstein need not be so scrupulous when he clarifies that “the researchers did not determine if there was a cause-and-effect relationship between payments and prescribing.” To deny that perks have a causal effect on physician behavior invites improbable considerations.

In fact, the data suggests that doctors are particularly easy to manipulate. One of the researchers interviewed by Ornstein was “surprised that it took so little of a signal and such a low value meal [to influence doctors]” A Chick-fil-A is all that it takes!

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In defense of the employed physician

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I wish to make one clarification and one prediction regarding employed physicians.

The clarification is this:  There is a common misconception that if healthcare operated under free market conditions, it would primarily be a cottage industry of solo practices and of small physician-owned hospitals.  Such operations would not develop the capabilities of large healthcare entities that we commonly associate with central planning.

In reality, however, the opposite would be the case.

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