Medicine • Philosophy
Every trouble in medicine begins when physicians serve the State rather than patients.
Below is my closing statement for the recent debate on brain death in which I participated. It starts with a reference to the fact that a declaration of brain death often requires that the examination be performed by 2 or more physicians.Continue reading “A lethal license to deceive”
I was invited to participate in a debate on “brain death” at the annual meeting of the Catholic Medical Association in Orlando this past week. The question was: “Are neurological criteria for the determination of death acceptable in Catholic health care?”
On my side was my friend Pete Colosi, and we argued the negative (i.e., that brain death is not true death, and harvesting organs from people who have been declared brain dead is homicide).
This topic is very dear to me. I have published 2 scholarly papers on brain death, refuting some of the more salient philosophical arguments that have been advanced to push the idea that brain death is true biological death. The most accessible of the 2 can be found here.
Below is my opening statement for the debate. I didn’t know if the audience would be familiar with the topic, so I tried to give a simple overview. I am adding a couple of footnotes here to expound on some key points.
A disputed question argued in the Scholastic style.
Objection 1. The unvaccinated are indeed a threat to others because the pandemic will only be overcome through herd immunity, and herd immunity can only be achieved safely and promptly through widespread vaccination. The unvaccinated are thus postponing the time until herd immunity is achieved and therefore are responsible for the heavy morbidity and mortality caused by this avoidable delay.
Objection 2. Asymptomatic infections with SARS-CoV-2 are known to occur and an unvaccinated person can transmit the virus to innocent bystanders. Therefore the unvaccinated are a threat to others.
Objection 3. The unvaccinated have an irrational fear of vaccines that is not supported by science. They have conspiratorial attitudes that are spreading through campaigns of disinformation, undermining public health institutions, and damaging social cohesion. Therefore the unvaccinated are a threat to others.
Objection 4. By minimizing the danger of the virus, the unvaccinated also dismiss the value of non-pharmacological interventions (NPIs) such as social distancing and masking. Their overall reckless behavior further contributes to the spread of the virus and to much morbidity and mortality. Therefore the unvaccinated are a threat to others.
Objection 5. The unvaccinated are much more likely to be hospitalized with COVID and to suffer severe complications that are costly to society than the vaccinated. Therefore the unvaccinated are a threat to others and should bear the cost of their healthcare if they persist in their refusal to be vaccinated.
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Sed Contra, as it is said, “The healthy have no need of a physician, but the sick do.” Therefore, being healthy, the unvaccinated have no need to be vaccinated and cannot be a threat for failing to do something they have no need to do.Continue reading “Are the unvaccinated a threat to others?”
The main reason we are seemingly so accepting of lockdowns and vaccine mandates is that we have been conditioned to view a pandemic or an epidemic as a war being waged on our society.
In wartime we naturally expect civil liberties to be suspended. Likewise, the reasoning goes, during a pandemic we need to act in a unified way under some central command to fight this viral existential threat. Individual rights and freedoms must be curtailed for the sake of the greater good.
But that’s a false analogy. A pandemic is not a war. It’s a natural disaster. (Granted, SARS-CoV-2 may not be so “natural” but still, the virus is not an “enemy” waging a war on us.) Continue reading “The pandemic war analogy: turning natural disaster into violent civil conflict”
[As this goes to press the Biden administration is proposing a sweeping vaccine mandate that may affect an estimated 100 million Americans, making the following considerations all the more relevant]
Dear_________,
I received your message detailing your concerns about receiving a COVID vaccine and requesting a medical exemption. I understand that your employer is now mandating a vaccine unless you can obtain such an exemption (or perhaps a religious one). I find your concerns perfectly legitimate but, unfortunately, they do not justify a medical exemption.
As you’ve noted yourself, there is no evidence that a history of prior myocarditis or prior atrial fibrillation increases the risk of getting myocarditis from the Pfizer or Moderna vaccines. And even if there was such evidence, then the J&J vaccine would be the alternative immunization to address that particular concern.
I also understand that your worries go beyond the possibility of having another bout of myocarditis (however small the chance may be). You have serious misgivings about these vaccines because you’ve lost confidence in the medical profession, the pharmaceutical industry, or the public health authorities (or perhaps all three).
Who can blame you? Can anyone deny that self-interest is all too often a prime motivator in healthcare—even in public health—and all too often at the expense of patients or the public? Abuses of confidence by doctors and hospitals, greediness in the pharmaceutical industry, and ideological or political pressure in the public health sector are all plainly evident and warrant at least some degree of skepticism. Your distrust is not paranoid, it is actually rational.Continue reading “Letter to a patient seeking a medical exemption to the COVID vaccine”
I recently participated in a debate opposing me to Professor Adam Cifu on the topic of “Evidence-based medicine in the age of COVID.” The debate took place on an episode of Dr. Chadi Nabhan’s Outspoken Oncology podcast. Dr. Saurabh Jha was the moderator and he did a great job keeping us on point and asking for important clarifications when needed. It was a fun and cordial moment and I found it intellectually fruitful. You can listen to it here or on any podcast platform. The discussion strengthened my conviction that the central issue about EBM is the conflation of the role of the physician with that of the clinical scientist.
That conflation was quite apparent in a recent online editorial published by Robert Yeh and colleagues on the topic of equipoise during the COVID-19 pandemic. Yeh at al. are accomplished academic cardiologists and outcomes researchers (Yeh was a guest on The Accad and Koka Report a couple of years ago).
I’ll get to their editorial in a moment, but equipoise is a term that I became aware of only in the last few years, mainly from mentions on MedTwitter. From those mentions I developed an intuitive sense of what equipoise must mean: a mental state of uncertainty about a treatment that prompts the medical community to seek a more definitive answer by way of a randomized controlled trial. For example, one might say “I’m not sure if hydroxychloroquine works to prevent or treat COVID-19. Based on the existing collective experience, there is equipoise about it. We need a clinical trial.”
That seems reasonably straightforward, but the editorial by Yeh et al. piqued my curiosity so I decided to look into the origin of the term and its introduction in the medical literature.
Soon after publishing our second podcast episode on brain death, this article from Newsweek came into my Twitter feed: “Endorestiform Nucleus: Scientist Just Discovered a New Part of the Human Brain.”
According to the article, an Australian researcher may have discovered an island of neurons heretofore undescribed and which may be involved in important motor activities.
The same article also mentions the “discovery” early this year of a new organ to be called the interstitium. As in the case of the endorestiform nucleus, the claim for the interstitium is not that scientists have discovered a new material part of the body so far unknown, but that a known part of the body that previously did not attract the attention of physiologists is now found to have a function that is capturing their attention.
These “discoveries” illustrate nicely a philosophical point about body parts. Continue reading “When scientists discover new body parts”
To conclude this 3-part series, I will discuss the relationship between shared decision-making (SDM) and evidence-based medicine (EBM), as the two are intimately connected.
As I indicated in part 1, SDM did not attract the attention of academics until the late 1990s. It is only then that publications on SDM began to appear routinely in the medical literature, and their numbers have exploded since the early 2010s (see chart). Yet shared decision-making was proposed by the Presidential Commission’s ethicists as far back as 1982. What accounts for the delay in interest?
The simple answer is that the development of SDM had to wait for the appearance of the evidence-based medicine movement on the healthcare scene in the early 1990s. And it makes perfect sense that SDM would require EBM to flourish, since EBM was proposed precisely as a scientific and objective antidote to “eminence-based medicine,” which is one expression of the culture of medical paternalism that SDM was supposed to be countering.Continue reading “The case against shared decision-making – part 3”
(This is the second part in a series on shared decision-making. Click here for part 1)
I recently attended a cardiology conference where a speaker proudly presented a case of shared decision-making. It involved a young female athlete who had survived a cardiac arrest and was diagnosed as having an anomaly in her heart conduction system, putting her at risk for arrhythmia during exercise.
She had received an implantable cardioverter-defibrillator and the decision in question had to do with whether she could resume sports activities or not. The guidelines issued by the American Heart Association recommend that activities be strictly limited in intensity, but the evidence to support that recommendation is scant.
The cardiologist told the audience that he and the young woman met several times and had long conversations. He got to know her very well. He took the time to explain to her everything that medical science has revealed about the potential risks of a future cardiac arrest under the circumstances. Together, they imagined various scenarios of what might happen if one course of action or another was taken, and what impact the athlete might personally experience in terms of overall quality of life.
Finally, they jointly agreed on a decision.Continue reading “The case against shared decision-making – 2”
In a matter of less than a decade, “shared decision-making” (SDM) has emerged as the uncontested principle that must inform doctor-patient relationships everywhere. Consistently lauded by ethicists and medical academics alike, it has attracted the attention of the government which is now threatening to penalize doctors and patients who do not participate in SDM prior to providing certain treatments, even if the legal process of informed consent has been fulfilled—and even if the treatment is widely considered to be clinically justified.
For example, in a recent issue of JAMA, an editorial approvingly reports that the Center for Medicare and Medicaid Services will soon refuse to pay physicians and hospitals for the implantation of cardioverter-defibrillators unless the decision to implant these life-saving devices was “shared” with the patient. Although the announcement is short on details regarding the formal process by which SDM must be documented to have occurred, the new policy certainly testifies to the unquestioned status SDM has rapidly acquired as a general principle of medical ethics.
Where does the idea of shared decision-making come from and how did it suddenly emerge to represent the highest of bedside virtues? I will present historical development of that concept in this post and examine its highly problematic aspects in more detail in subsequent articles.Continue reading “The case against shared-decision making”
