Ethical Issues in Health & Medicine

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Tuesday, January 26th, 2010

As we gain better and better control of the body and its health, we are exposed to worse moral dilemmas.  Here are some of the toughest ethical issues in health & medicine.

Being a medical ethicist has never been harder.

1) Genetic modification

The complete sequencing of a copy of the human genome was a tremendous breakthrough.  Since then, however, treatments and cures based off of genetics have been limited.

That said, right now innovative treatments based off genetic modification are becoming more and more plausible.  For instance, recently a man was cured of AIDS when he received a bone marrow transplant (because he also had leukemia).  We are reaching the stage where we might be able to harvest some cells from your body, inject them with new genetic material, and put them back in.

Another area of concern is that of “designer babies.”  We are now able to tell at an extremely early stage if a baby will have certain genetic disorders.  And that allows selective abortions to take place, which can prevent tragedies like a child who will die an agonizing death over several months.  It can also allow selection for traits like sex and even height.

It could get worse.  We could reach a point where fetuses are normally removed from the womb, injected with genetic data, and reimplanted.

This can lead to a society where only the rich can afford to make their babies healthier, smarter, better looking.

2) Premature babies

We are turning the clock back on when a baby needs to be born in order to survive.  As science gets better and better, extremely premature babies have switched from certain death to possible struggle to survive.

The problem is that such care can be very expensive and doesn’t guarantee health.  A baby could survive with retardation and barely functional lungs, for instance, at the cost of several million.  By contrast, that same money could have saved hundreds of fully healthy people from starvation.

(Can you imagine having to tell a parent that?)

Being able to save babies that are very young also indirectly threatens the morality of abortion.  If a month old fetus could live a happy and healthy life if supported in a laboratory, it somehow seems more of an ethical quandary to commit an abortion.

3) Performance Drugs

As we understand the brain in greater detail, we are able to develop drugs that stimulate it.  This has proven a life-saver for the millions of people with attention deficit disorder, and could be a tremendous breakthrough for those suffering from Alzheimer’s disease.

It could also, however, be of great use to normal people.  If a pill could improve your memory, focus and concentration – why not take it?  This also leads to a slippery slope.  You can imagine a workforce where it is the culture to take performance enhancers routinely, and your boss yelled at you if you didn’t do so as well.

This pressure to take pills for focus is already intense at the best schools.  Spend time in the library at any top college, and you will overhear students talking about using pills like Adderall for better focus and attention.

4) Resuscitation and Life Support

With modern technology, we can keep people alive for a long time.  In the vast majority of cases, this has proven a godsend, and can be of especial use to save someone who has slipped into a temporary coma.  It has, however, led to controversy.

Is it worth spending a large amount of resources on keeping someone who is totally brain-dead alive?  Some medical ethicists have reported that question is on the easier side of what they face!

Imagine you’re a doctor operating on a patient whose life you could save.  But if you do, they will spend their entirely life completely immobilized, only able to move their eyes.  Worse, they would be in tremendous pain.

Fully conscious but unable to do anything whatsoever.

All you would have to do to prevent this from happening is slow down a little.  If your operation took 2 hours instead of 1 and a half, the patient would die.  And no one would ever know.

That’s an ethical dilemma.

5) Euthanasia

What do you do when someone is undergoing a slow, horrible death – and they want your help out?  People who suffer from amyotrophic lateral sclerosis slowly become paralyzed and lose the ability to swallow or talk and eventually die.

What on earth do you do for someone who has that and wants to die?

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general interest

Intuniv for ADHD: Efficacy, Side Effects

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Sunday, September 6th, 2009
Guanfacine or Intuniv Tablets

Intuniv for treating ADHD

The FDA approved Shire’s Intuniv medication as a once-daily treatment for ADHD on September 3, 2009. Intuniv is an extended release formulation of guanfacine, a blood pressure med that has been on the market for quite some time.

There have only been several studies done into the efficacy, safety and profile of use of Intuniv for treating ADHD.  So far, they say that Intuniv works somewhat less than the stimulants like Ritalin and Adderall and probably somewhat more than the traditional non-stimulants like Strattera.

30% of people can’t take or don’t respond to stimulants.  Parents in particular have concerns about traditional treatment for their children – so there is a lot of excitement around Intuniv.

The pros: Intuniv could possibly fill a lot of the role as a non-stimulant treatment that Strattera was supposed to play but didn’t.  It has a long duration of effect and can even be used in combination with stimulants. And the short acting form of Intuniv has been on the market for some time, so we know a little about its safety and side effects.

The cons: Intuniv is very new, and it is still unclear just how effective it works.  Some studies have hinted at potential problems such as high rates of serious side effects such as fainting and possibly even suicidal thoughts.  While the short acting form has been on the market, Intuniv is long lasting.

Remember, roughly 50% of medication side effects are discovered after it is released onto the market.

Efficacy

How well does Intuniv work?

The studies seem to show that Intuniv falls just short of sending ADHD symptoms into remission.  Roughly 55% of those on Intuniv in one study reported significant improvement compared to 30% of those on placebo.

In one major study, on one scale, people who started with an ADHD score of around 40 and took Intuniv had their score go down to around 19 on average. The accepted number for remission of ADHD symptoms is a score of 18 or less.

Those who took Intuniv along with stimulants went from about a starting score of around 29 to around 13.

There are some more interesting hints towards Intuniv’s efficacy we found in that study.  On the one hand, only 10% of participants said that they stopped specifically because they thought Intuniv wasn’t working that well.  And of those taking Intuniv with stimulants, only one person stopped specifically because it wasn’t working well.

That said, around 80% of people in total dropped from that study.  It was done over two years, but that is still a somewhat high number.

Other studies into Intuniv have had much lower drop out rates.

In another, smaller study, roughly 30% of people on placebo reported significant improvement, as compared to around 55% of those treated with Intuniv.  This difference likely means that it has some benefit and is useful but falls short of the efficacy of the stimulants, which work in roughly 70% of those treated.

Analysis of that study concluded that at low doses Intuniv is about as effective as traditional non-stimulants, and at higher doses is superior to the current non-stimulants, such as Strattera, Wellbutrin, and possibly even Provigil.

Intuniv Side effects

Different studies show different side effect profiles for Intuniv.  Some say that it has about the same rate of issues as placebo, while others show that around 10-15% stop using it because of some side effect.  As far as psychoactive drugs, a 10-15% discontinuation rate due to side effects is on the lower/medium range.

The side effects of Intuniv also depend on its particular use.  When used in combination therapy with stimulants, for instance, it has much less rates of sedation and sleepiness, and users seem to report less problems.  This is probably because its sedative effects that lower blood pressure are counteracted by the stimulants effect of raising it.

Some of its side effects take time to start showing up, with sedation in particular starting after 3 weeks of treatment.

Most common:

30-40% report sleepiness

25% report headache

17% in one study reported upper respiratory tract infection

10% report sedation

Other common side effects include dizziness, nausea, irritability and reduced salivary flow.

Concerns

In one study, 5 participants out of 262 who took Intuniv  experienced syncope, or “temporary loss of consciousness.” In layman’s terms, they fainted or blacked out.

The clinical trials dedicated to exploring safety did not have such incidences, and it’s possible that the syncope events were environmentally based. One of the sufferers, after all, had a history of such issues. And guanfacine has a long history of use. So while those numbers are alarming, they are explainable.

Other possible side effects that may be an issue: head injury, suicidal ideation.

Like with all psychoactive medications, people using Intuniv should be monitored for anything abnormal like increased feelings of depression.

Dosing

Intuniv is given typically anywhere from 1-4mg/per day.  A dose typically lasts for 12 hours, but may have some effect for up to 24 hours.

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adhd

The Winter and Swine Flu: How Bad is it?

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Thursday, September 3rd, 2009
A black pig with the words Swine Flu on it

Swine flu, H1N1

Swine flu has hit us hard already, but with winter, the worst may be yet to come.

We’re likely to get massive incapacitation and illness.

Still, so far swine flu isn’t a big killer. In the Spring, roughly 800,000 New Yorkers had symptoms of swine flu, but only 54 died of it. The worst fatality rates have been seen in Mexico, which helped spread initial panic, but elsewhere it has been milder.

The bad news

Swine flu is unusually contagious. If you’re living with someone who catches the flu, normally you’d have around a 10-15% chance of catching it. If you’re in close contact with someone who has swine flu, by contrast, you have a 20-30% chance of infection.

Because of this much higher rate of spread, it’s entirely possible that 1/3 of the USA will be infected, and one much quoted White House report says it may be up to 1/2.

More bad news. Swine flu and the regular seasonal flu are quite different, which looks like it might be a serious problem. It’s entirely possible that come winter we’ll have a normal flu season – and have Swine Flu on top of that.

This is especially serious when you realize that Swine flu tends to infect younger people.  So a wider range of people and at higher numbers might catch the flu this winter.

The good news

It’s possible that Swine flu will simply overtake seasonal flu and that we won’t have extremely large numbers of people infected.

Best of all, Swine flu doesn’t seem to be  mutating to become more dangerous. From April to late July, for instance, the genetic structure remained mostly constant. And a recent study showed that swine flu doesn’t tend to remix with other influenza strains, meaning less risk of a deadly recombination.

Vaccines to swine flu are very rapidly being made. It has yet to be seen how effective they are, and if they will be ready in time. And because of the incredible time pressure, we’re simply not going to get the safety data we need and typically require for any health related product.

But they are being made, and they may help fight the spread of swine flu.

Leave with this message.  Unless you have very strong reasons not to, get the flu vaccine we do have.

We’ll next cover how to recognize if you have swine flu and what to do if you or a loved one has it.

You might like:

What is Swine Flu?

If this article helped you, I’m happy.  Thanks for reading!

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news

How To Improve Health Care in the USA

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Friday, August 28th, 2009
A Black Stethoscope Lying on a Table

Obama is trying to change the health care system in America.  I agree with him that there needs to be change.  What’s not entirely clear is what his ideas actually are.

The fact is, we spend among the most on health care of all the major nations, and aren’t getting better health care.  We all have similar life spans and health results.

That said, our system does have its advantages.  The USA has produced the vast majority of the innovations in medicine over the past 50 years.  The free market is a powerful tool, and those who opposed it have been buried by the sands of time.

Yet we need change.  The system has become broken.  Here are 5 specific ideas that can make a significant impact on the quality and cost of health care in the USA.

1) Publicly funded research should be repaid

The National Institute of Health, or NIH, funds hundreds of millions of dollars of research. Sometimes that research plays a major role in the development of a medication.

The best selling cancer medication, Taxol, was in a large part discovered due to taxpayer dollars. The NIH invested $484 million in its development.

With that kind of investment, it only makes sense that the NIH should have significant ownership of the medication and get repaid. Taxol is a billion dollar drug, after all.

But as is, the government is heavily subsidizing research and not getting repaid. For Taxol, Bristol-Myers Squibb generously agreed to pay the NIH 00.5% of sales, a promise it actually didn’t even meet.

It’s absurd. Hundreds of millions of our tax-payer dollars go to develop drugs that are then sold to us at exorbitant prices.

When we’re the ones subsidizing the research, we should either get repaid by a percentage of revenue, or by our representative – the FDA and NIH – having a stronger say in drug pricing.

2) Recommend options

The fact is that there are hundreds of medications on the market, and for any given class, say cholesterol lowering pills or antidepressants, there are many, many options. Often one medication isn’t necessarily any better than another. They just cost different amounts and tend to have different side effects.

An impartial analyst should look at all the options and propose a best practice choice – a medication that works best in the cost-benefit analysis, including economic cost. While not binding, having an official recommendation based off good science will certainly help doctors make better prescribing choices.

And those choices will save money by avoiding expensive variants that don’t show significant advantage over the existing options.

3) Require improvement over old

The FDA should be able, in exceptional cases, to require a medication prove itself against existing options. When the consumer already has 20 options that are all essentially the same, the FDA should be able to require new medications to prove their efficacy not against just placebo but against the existing options.

This will fight the proliferation of me-too drugs. And it will promote research into new classes of medication, something that has been lacking.

4) Improve the patent law

Drugs are rightfully protected by patents. Unfortunately, those laws have become abused by drug companies to aggressively bully generic manufacturers. They have also become exploited by allowing minor changes to extend the patent and keep costs up.

Right now, once a drug goes off patent, the parent company typically sues the first generic manufacturer to prevent competition. These preemptive lawsuits hurt the consumer greatly, because they can delay the introduction of generics by thirty-months.

It’s an abuse of the law to thwart the market.

5) Strengthen dietary supplement control

In 1994, a law was passed that significantly reduced the control of the FDA over dietary supplements. As long as they avoided making any specific health claim, they didn’t have to pass the stricter controls that drugs typically undergo.

The result? Half of dietary supplements don’t contain what they claim or are poorly manufactured. Some are even contaminated with lead.

Poor quality dietary supplements have become a chronic problem. In August 2009 alone, several were recalled. Weight loss supplements are particularly thorny, as they have tended to contain amphetamine-like compounds that potentially cause heart problems.

We need stronger control of health supplements.

You might like:

50 Ways to Making Friends

Help – I think I’m losing my mind!

Sources:

Powerful Medicines, Jerry Avorn, M.D
Understanding the Antioxidant Controversy

http://healthlifeandstuff.com/2009/07/24-ways-to-make-friends-improve-relationships/
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general interest

Are Cholesterol Target Levels Too Low?

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Wednesday, August 19th, 2009
test

Coronary heart disease (CHD) is the single biggest cause of health problems and death in the USA and the world.

Statins offer a way to help treat CHD, but have become perhaps too heavily pushed. And the target level of cholesterol to reach may have been lowered too far.

What causes CHD?

CHD is most often caused by the build up of plaques on arteries and other blood carrying vessels. The plaque is made of various components, but deposits of cholesterol tend to play a key role. When it becomes too thick, it can stop blood flow, causing a heart attack or other damage.

The plaque can also break off and float around the body. If that happens, it can harmlessly dissolve. Or it can clog a blood vessel pretty much anywhere, potentially causing a stroke, heart attack, or thrombosis.

Statins discovered

The late 1980s heralded the discovery of a class of drugs called the statins.

These medications, technically termed 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, lower levels of cholesterol. Because of the role cholesterol plays in plaque formation, the statins were found to dramatically decrease risk of serious heart damage.

Statins were so effective that a lot of influential doctors argued that the lower cholesterol levels were, the better. LDL, or low density lipoprotein, was specifically targeted. And in the early 2000s, aggressive new targets for treatment were released. LDL levels should be lowered below 100 mg/dL.

But a lot of the proponents of the new, lower levels were found to be on the pay for major drug companies. And it’s not entirely clear if aggressive lowering of LDL levels provides the most benefit.

LDL must be lowered?

It’s most likely that lowering of LDL follows a logarithmic pattern. In at risk patients, a small reduction provides a major reduction in risk of having a heart attack. As levels are lowered even further, however, the benefit becomes increasingly smaller.

A few major studies support the idea that LDL levels shouldn’t be over aggressively lowered. The HARP study showed that lowering levels below 100 mg/dL showed no increased benefit.

The WOSCOPS study gave similar results, as well as AFCAPS.  Additionally, several major studies into the non-statin drug Ezetimibe showed that its reduction of LDL did not mean better clinical results for patients.

Potential side effects:

There may be a downside to over aggressive treatment.  Low levels of LDL may theoretically contribute to hemorrhagic stroke. Statin therapy does have side effects including myopathy and we know especially little about the effects of the high doses needed to achieve the lowest levels of LDL.

Some data show a slight increase in certain types of cancer for statin use, although such an effect may be statistically insignificant.

Conclusion

There is no doubt that statins have played a major role in reducing heart disease across America. But it is also not entirely clear who should be given them, and how heavily they should be used.

With the guidelines for cholesterol treatment being written substationally by doctors on the payroll of major drug companies, skepticism is called for.

Sources:

The Aggressive Low Density Lipoprotein Lowering Controversy
“The Lower the Better” in Hypercholesterolemia Therapy: A Reliable Clinical Guideline?

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general interest

Red Wine and Proper Diet

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Wednesday, July 29th, 2009
test

What impact does food have on our health, both mental and physical?

A pretty big one.

One out of four Americans suffers from some sort of mental disorder, significantly more than in China and other countries, part of which may be because of diet.

And French people have a 40% less risk of heart infarction compared to the rest of Europe, though this contention – called the “French paradox” – is highly argued.

Eskimos consume very high fat diets yet tend to have lower risk of heart disease.  The answer may lie in their consumption of certain fish with important fatty acids.

Depression, a common malady, has been linked in part to dietary decisions.  Increasing folic acid, magnesium and Vitamin B12 may help treat depression.

A good diet at its basics has a combination of fruits, vegetables, whole grains and fish.  Studies tend to show that adding one serving of fruits and vegetables daily significantly reduces risk of heart disease and possibly stroke.

Red Wine

Consumption of two or fewer servings of wine daily has been shown to reduce risk of heart disease.*

Red wine is very high in natural substances called polyphenols, containing more than 200 of them.  They are powerful anti-oxidants, which means they help prevent degeneration and aging of your cells.

Importantly, red wine has resveratol, a substance that has been shown to increase the lifespans of various animals, but not mice.  Resveratol is a plant antibiotic that seems to fight the formation of cancer at every step of the process, including inhibiting ribonucleotide reductase and other carcinogenic processes.

Resveratol may also fight brain disease and help keep your blood healthy.  Research has not caught up with all the exciting claims made about resveratol, however.

Red wine – in moderation – may also help lower cholesterol and help your innate immune system.  Some research shows that regular consumption of small amounts of red wine can help both women and men with sexual response and enjoyment, though those studies have been with small samples and need verification.

*Note: the American Heart Association does not recommend drinking, and consumption of three or more drinks daily is associated with heart disease and stroke.

You might like:

The Health Benefits of Simple Foods
50 Ways to Make Friends

Sources:
Resveratrol and its analogs: Defense against cancer, coronary disease and neurodegenerative maladies or just a fad?
A systemic review of the roles of n-3 fatty acids in health and disease

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diet

10 Questions to Improve Your Life

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Sunday, July 19th, 2009
Smiling Woman

Questions are more powerful than statements.  They leave something unresolved, which creates room for the mind to fill in.

A question can turn your world upside down.

1) How can I make exercising fun?

2) What can I do that my grandkids will be proud of?

3) Who will calm you on a Monday night at 1am when your heart is broken?

4) Who am I holding a grudge against?  Why?

5) What does my gut feeling say?

6) What makes me happy?

7)  How can I help my community?

8) How can I make new friends?

9) How can I spend less time doing things I hate?

10) What’s an interesting new magazine that I can subscribe to?

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self-improvement

Eat Simpler, Be Healthier!

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Wednesday, July 15th, 2009
test

Over the past 30 years, we’ve learned a lot about what food does to our bodies.  It doesn’t just give us energy.

What we eat plays a big role in how we feel and helps determine if we suffer from conditions like hypertension, diabetes or cancer.

Eating fast-food and artificial, chemical laced goo like doughnuts lays waste to our bodies and gets us addicted to sweeteners.

Focus on eating simple, basic foods.  They have surprising health benefits and are what our bodies naturally need.

Tea

Drinking several cups of tea a day may reduce blood pressure and promote a healthy immune system.  Interestingly enough, tea reduces the amount of sugar in your saliva.  It also naturally contains fluoride.  That means it also helps fight cavities.

Eggs

Eggs contain choline, a cognitive booster.  They also provide selenium and Vitamin K, in addition to essential proteins.

They may not be so bad for your cholesterol, too.  Recent research shows that eating more than four eggs a week didn’t raise cholesterol that much.  But as always, when in doubt, check with your doctor.

Honey

Made up of more than 180 compounds, honey contains flavonoids like apigenin and acacetin.  Eating honey may thicken your stomach mucus, reduce acidity, and help prevent ulcers.

Importantly, honey has been shown to reduce the effectiveness of viruses and bacteria, even possibly killing them.

Cranberry

Myricetin and quercetin are among the ingredients that might make cranberry effective in reducing risk of cancer.  It’s also theorized that cranberry can prevent and possibly help cure uterine tract infections.

Research shows that cranberry reduces bad lipids in blood and assists with healthy inflammatory response, both of which help your heart out.

Remember

In having a healthy diet, the key is diversity and simplicity.  Eat meats, fruits and vegetables along with carbohydrates.  Eating fish is good as well.

  • If a food didn’t exist 100 years ago, it’s probably not too healthy.

A good diet can help you feel and think better.  Deficiencies like not enough Vitamin B12 have a real impact on your life.

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diet