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Jack Sisson's Life Ethics Blog

We must find new ways through many ethical issues, especially regarding bioethics, medical ethics, and criminal justice. Jack Sisson's 'Life Ethics' blog focuses on numerous areas of concern, including the philosophical and ethical dilemmas surrounding stem-cell research, abortion, medical research, and health care.

 

From PR News Wire:


The National Coalition for Homeless Veterans has announced that President Barack Obama and First Lady Michelle Obama have been selected as recipients of the 2012 Jerald Washington Memorial Founders' Award, the highest honor bestowed by the nation's homeless veteran assistance community.
President Obama is the first person to receive the award more than once. He was honored in 2009 as the first president in U.S. history to make ending veteran homelessness a priority of his administration. Within months of that event, Secretary of Veterans Affairs Eric Shinseki announced the "Five-Year Plan to End Veteran Homelessness," an ambitious initiative to ensure veterans in crisis will never again be left to fend for themselves on the streets.
By June 2010, every member of the president's cabinet had signed onto "Opening Doors: Federal Strategic Plan to Prevent and End Homelessness," the nation's first comprehensive blueprint for multi-agency cooperation to end all homelessness in America. That historic document incorporated Secretary Shinseki's Five-Year Plan, which calls for increased access to housing, health care, income supports and homelessness prevention assistance for veterans and their families.
"Since the announcement of the Five-Year Plan, President Obama has consistently demonstrated his commitment to ending veteran homelessness in his budget requests to Congress," said Patrick Ryan, Chairman of the NCHV Board of Directors. "His budget submission for FY 2013 brings the nation to within reach of that goal. Secretary Shinseki and Department of Housing and Urban Development (HUD) Secretary Shaun Donovan have dramatically improved the systems in place to help veterans in crisis; and the steady decrease in the number of homeless veterans since 2009 is a testament to the president's leadership."
According to the most recent Annual Homelessness Assessment Report to Congress (December 2011), there were 67,495 homeless veterans on a single night in January 2011. That represents a decline of more than 56% since the president was sworn into office.
"By any account, a tremendous achievement," said John Driscoll, NCHV President and CEO. "And we're not yet at the midway point of the Five-Year Plan. The president's FY 2013 budget request would bring the number of HUD-VA Supportive Housing (HUD-VASH) vouchers to 60,000, the number needed to end chronic homelessness among veterans with serious mental illness and other disabilities."
It would also triple the amount of funding to help at-risk veteran families avoid homelessness, and provide rapid rehousing assistance for veterans working their way out of homelessness. For the second straight year, President Obama's budget request provides record funding for the VA Grant and Per Diem Program, which provides transitional housing, health services, employment preparation and job placement assistance to more than 30,000 homeless veterans each year through local integrated service delivery systems.
"Under the leadership of President Obama, we are witnessing unprecedented national unity in the campaign to end and prevent veteran homelessness," Ryan said. "The progress we have seen from the federal agencies, the Congress, the community partners NCHV represents, and the American people in just the last three years give rise to the expectation that this campaign will succeed."

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From The Wall Street Journal:

Nearly two out of three Americans don’t follow their doctor’s orders properly when taking prescription drugs, neglecting to take their medications or seeking out pills that weren’t intended for them, according to new research.

The findings point to the nation’s growing problem with prescription-drug abuse, according to Quest Diagnostics, which analyzed nearly 76,000 urine samples submitted last year from doctors’ offices and Quest’s patient-service centers. Results were matched with physicians’ records of the drugs prescribed for each patient. Subjects remained anonymous and results from patients of drug-rehabilitation clinics weren’t included.

The results indicated 63% of people on prescription drugs strayed from their doctor’s orders, Quest says, and many of the drugs found were painkillers, sedatives or amphetamines that weren’t prescribed for the sampled patient. Researchers tested for 26 commonly prescribed and abused medications and for illegal drugs, such as marijuana and cocaine. Samples were taken from 46 states and the District of Columbia.

“People have such tremendous access to very powerful prescription drugs,” Jon R. Cohen, Quest’s chief medical officer, tells the Health Blog.

Of the people that didn’t follow their doctors’ orders, two in five weren’t taking any medications even though they had been prescribed, suggesting some people can’t afford them, skip treatments or even divert them to the black market, Quest says. The remaining 60% of misusers were taking medications that weren’t prescribed by their doctors.

Many people also combined drugs without a doctor’s oversight, which is dangerous because of how some medications can interact with each other, Cohen says. Results of misuse were consistent across income levels, gender and the level of health coverage, he adds. One limitation of the study, it notes, is that some patients may have been tested because their doctors suspected misuse. Others were randomly selected.

Health officials have said enough painkillers were prescribed in 2010 to medicate every U.S. adult around the clock for the month. The abundance of prescription painkillers — obtained, in many cases, by swiping pills from a medicine cabinet, rather bought at the street level — helps explain the high level of misuse, says Robert Stutman, a former Drug Enforcement Administration official who consulted with Quest on the project.

Americans “don’t inherently throw our pills away, so they sit in a medicine cabinet, unused,” Stutman says.

Link to The Wall Street Journal.

Question: How many of you have prescriptions which a doctor or dentist prescribed that you later discovered can interact with each other in negative ways?

Answer: I have several that I'm not sure my doctor and/or dentist even considered when prescribing new ones.

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From Florida Today:

Mixing household cleaners can be deadly — ammonia and bleach together generate potentially lethal gas. Mixing medications can be equally dangerous, yet physicians still prescribe combinations such as Viagra and nitrate heart medicines. Such mismatches can prove fatal.

In one case, a man who had received a heart transplant was taking drugs to prevent rejection of his new organ. They included azathioprine, cyclosporine and prednisone. His primary-care physician detected high uric-acid levels and prescribed allopurinol. This landed the 52-year-old in the hospital with a life-threatening blood disorder (Pharmacy Times online, July 1, 2006).

This potentially deadly combination should never have happened. The danger of this interaction has been known for more than 40 years. But doctors don’t always recognize which drugs should never be used together. When prescribers were tested about their knowledge of drug interactions, they performed miserably (Drug Safety, June 2008). They were given 14 drug pairs to classify as forbidden, risky or not a problem. They got the right answer on fewer than half the pairs.

Any high-school student who scored below 50 percent on a test would fail. It isn’t hard to understand why doctors can’t remember dangerous drug interactions. With thousands of medicines available, the number of bad combinations could reach into the hundreds of thousands. This is beyond the capability of human memory.

That’s why there are computers and smartphones. Many physicians and all pharmacists now rely on electronic databases for writing and filling prescriptions. These tools provide warnings about drug incompatibility. But a recent study found that even when physicians had access to a wireless handheld device with interaction information, they were just as likely to prescribe a bad combination (Journal of Managed Care Pharmacy, January-February 2012).

Don’t assume the prescriber is aware of all the drugs a patient is taking or the hazards of mixing medicines. Our book “Top Screwups Doctors Make and How to Avoid Them” (online at www. peoplespharmacy.com) has tips for preventing deadly interactions. Anyone who takes more than one pill at a time should always trust, but verify.

Joe Graedon is a pharmacologist. Teresa Graedon holds a doctorate in medical anthropology and is a nutrition expert. Their syndicated radio show can be heard on public radio. In their column, Joe and Teresa Graedon answer letters from readers. Write to them via their website:www.PeoplesPharmacy.com.

Link to Florida Today.

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From Fox News:

Prescription pills used to treat severe acne were linked to a two-fold risk of developing eye problems, such as pink eye, styes and dryness, in a large new study from Israel.

Isotretinoin, which goes by brand names including Roaccutane, Claravis and Amnesteem, is known to have serious side effects, such as bone growth delays in teenagers and miscarriages and birth defects when taken by pregnant women.

The medications are quite popular, however, for treating severe cases of acne in both teens and adults.

According to Roche, the maker of Roaccutane, formerly known as Accutane, 16 million people worldwide have used that brand alone since 1982.

Some eye problems are already more common in people with acne, but in the new study of nearly 15,000 Israeli adolescents and young adults, 14 percent of those taking isotretinoin were treated for eye conditions within a year of starting the drug.

That compared to seven percent of an acne-free comparison group and 9.6 percent of subjects with acne who had never taken isotretinoin.

"I would give parents the advice to (have their children) see an ophthalmologist before they take it, and every three months for the first year they take it, because if we catch things early we can fix them and not leave you with permanent side effects," said Dr. Rick Fraunfelder, a professor at Oregon Health and Science University and an expert in eye problems related to medications.

Although eye problems have been documented among people taking the drugs, Fraunfelder, who was not involved in the new study, said past research has not detailed how common the issues are.

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From Clark, Purdue and List Company, LPA -- a Personal Injury Law Blog


Pradaxa, also known as dabigatran, is being investigated by the Food and Drug Association as potentially dangerous drug. Pradaxa is a prescription medication used as a blood thinner, and is manufactured and sold by Boehringer Ingelheim. Pradaxa was approved by the Food and Drug Administration in October 2010. Since it was approved by the FDA, approximately 1.1 million prescriptions for Pradaxa have been written.

Pradaxa was the first in a new class of medications called "direct thrombin inhibitors." Pradaxa was intended to be used to prevent strokes in people with atrial fibrillation and was designed to replace warfain as a blood thinner. While excessive bleeding caused by warfarin can be counteracted with vitamin K, there is no antidote for excessive bleeding caused by Pradaxa.

Recently, Pradaxa has been implicated in 260 reports of fatal bleeding worldwide. The death of an elderly man from a massive brain hemorrhage following a routine fall indicates that bleeding complications from Pradaxa are irreversible. This death spurred the FDA to issue a Drug Safety Communication reporting the initiation of a safety investigation into reports of serious bleeding. According to doctors from the University of Utah, an 83 year old man was seen at a medical center after a routine fall. Initially, he was fully alert and oriented and his neurological exam did not raise concern. However, within 2 hours, additional CT scans revealed extensive brain hemorrhage. All efforts to stop the hemorrhaging failed and the man went into a coma and died shortly thereafter.

In October 2011, the Institute for Safe Medication Practices released a report stating that Pradaxa was named in more FDA adverse event reports than over 98% of medications monitored by that group. Patients with impaired renal function are particularly susceptible to adverse side effects from Pradaxa because their kidneys are unable to flush all of the drug from the body resulting in an excessively amount of Pradaxa in the system.

Original source for material.

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From The Wall Street Journal:


Corrections & Amplifications

The article below quotes Robert Truog, professor of medical ethics, anesthesia and pediatrics at Harvard Medical School, about the possible pain felt by an organ donor who has been declared brain dead. Mr. Teresi writes that Dr. Truog "compared the topic of pain in an organ donor to an argument over 'whether it is OK to kick a rock.' " A review of Mr. Teresi's notes after the publication of the essay reflects that Dr. Truog, when asked whether a donor feels pain, said "it's like kicking a rock." Dr. Truog, however, denies that he used the analogy. "I can tell you in the strongest possible terms that I am certain I never said anything like this." In a separate issue, recipients of single-organ transplants—heart, intestine, kidney, liver, single and double lung and pancreas—are charged an average $470,000, ranging from $288,000 for a kidney transplant to $1.2 million for an intestine transplant, according to consulting firm Milliman. A previous version of this article incorrectly said that average recipients are charged $750,000 for a transplant, and that at an average 3.3 organs, that is more than $2 million per body.

The last time I renewed my driver's license, the clerk at the DMV asked if she should check me off as an organ donor. I said no. She looked at me and asked again. I said, "No. Just check the box that says, 'I am a heartless, selfish bastard.'"
Becoming an organ donor seems like a win-win situation. Some 3.3 people on the transplant waiting list will have their lives extended by your gift (3.3 is the average yield of solid organs per donor). You're a hero, and at no real cost, apparently.

But what are you giving up when you check the donor box on your license? Your organs, of course—but much more. You're also giving up your right to informed consent. Doctors don't have to tell you or your relatives what they will do to your body during an organ harvest operation because you'll be dead, with no legal rights.

The most likely donors are victims of head trauma (from, say, a car or motorcycle accident), spontaneous bleeding in the head, or an aneurysm—patients who can be ruled dead based on brain-death criteria. But brain deaths are estimated to be just around 1% of the total. Everyone else dies from failure of the heart, circulation and breathing, which leads the organs to deteriorate quickly.
The current criteria on brain death were set by a Harvard Medical School committee in 1968, at a time when organ transplantation was making great strides. In 1981, the Uniform Determination of Death Act made brain death a legal form of death in all 50 states.

The exam for brain death is simple. A doctor splashes ice water in your ears (to look for shivering in the eyes), pokes your eyes with a cotton swab and checks for any gag reflex, among other rudimentary tests. It takes less time than a standard eye exam. Finally, in what's called the apnea test, the ventilator is disconnected to see if you can breathe unassisted. If not, you are brain dead. (Some or all of the above tests are repeated hours later for confirmation.)

Here's the weird part. If you fail the apnea test, your respirator is reconnected. You will begin to breathe again, your heart pumping blood, keeping the organs fresh. Doctors like to say that, at this point, the "person" has departed the body. You will now be called a BHC, or beating-heart cadaver.

Still, you will have more in common biologically with a living person than with a person whose heart has stopped. Your vital organs will function, you'll maintain your body temperature, and your wounds will continue to heal. You can still get bedsores, have heart attacks and get fever from infections.

"I like my dead people cold, stiff, gray and not breathing," says Dr. Michael A. DeVita of the University of Pittsburgh Medical Center. "The brain dead are warm, pink and breathing."

You might also be emitting brainwaves. Most people are surprised to learn that many people who are declared brain dead are never actually tested for higher-brain activity. The 1968 Harvard committee recommended that doctors use electroencephalography (EEG) to make sure the patient has flat brain waves. Today's tests concentrate on the stalk-like brain stem, in charge of basics such as breathing, sleeping and waking. The EEG would alert doctors if the cortex, the thinking part of your brain, is still active.

But various researchers decided that this test was unnecessary, so it was eliminated from the mandatory criteria in 1971. They reasoned that, if the brain stem is dead, the higher centers of the brain are also probably dead.

But in at least two studies before the 1981 Uniform Determination of Death Act, some "brain-dead" patients were found to be emitting brain waves. One, from the National Institute of Neurological Disorders and Stroke in the 1970s, found that out of 503 patients who met the usual criteria of brain death, 17 showed activity in an EEG.

Even some of the sharpest critics of the brain-death criteria argue that there is no possibility that donors will be in pain during the harvesting of their organs. One, Robert Truog, professor of medical ethics, anesthesia and pediatrics at Harvard Medical School, compared the topic of pain in an organ donor to an argument over "whether it is OK to kick a rock."

But BHCs—who don't receive anesthetics during an organ harvest operation—react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes.

What if there is sound evidence that you are alive after being declared brain dead? In a 1999 article in the peer-reviewed journal Anesthesiology, Gail A. Van Norman, a professor of anesthesiology at the University of Washington, reported a case in which a 30-year-old patient with severe head trauma began breathing spontaneously after being declared brain dead. The physicians said that, because there was no chance of recovery, he could still be considered dead. The harvest proceeded over the objections of the anesthesiologist, who saw the donor move, and then react to the scalpel with hypertension.

Organ transplantation—from procurement of organs to transplant to the first year of postoperative care—is a $20 billion per year business. Recipients of single-organ transplants—heart, intestine, kidney, liver, single and double lung and pancreas—are charged an average $470,000, ranging from $288,000 for a kidney transplant to $1.2 million for an intestine transplant, according to consulting firm Milliman. Neither donors nor their families can be paid for organs.

It is possible that not being a donor on your license can give you more bargaining power. If you leave instructions with your next of kin, they can perhaps negotiate a better deal. Instead of just the usual icewater-in-the-ears, why not ask for a blood-flow study to make sure your cortex is truly out of commission?

And how about some anesthetic? Although he doesn't believe the brain dead feel pain, Dr. Truog has used two light anesthetics, high-dose fentanyl and sufentanil, which won't harm organs, to quell high blood pressure or heart rate during harvesting operations. "If it were my family," he said, "I'd request them."
—Mr. Teresi is the author of "The Undead: Organ Harvesting, the Ice-Water Test, Beating-Heart Cadavers—How Medicine Is Blurring the Line Between Life and Death."Link toThe Wall Street Journal here.

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This is a little different from most of our posts, but it's a beautifully written piece that raises some of life's most difficult questions. In fact, I'm going to post it on both of our blogs, for while the topic of Alzheimer's certainly belongs on the TBI Blog, other issues raised in this tale beg for discussion in Life Ethics.


One morning late last year I awoke from a dream about writing a book, and the storyline was detailed: an older woman, recently diagnosed with dementia, had enlisted  the help of a younger man, perhaps her son, to guide her on a hike into the mountains, where she intended to let herself die by exposure to the elements.  They had to hide the reason for their mission from her family, but were both convinced of the rightness of what they were doing.

It wasn’t a bad dream, on the contrary, I was quite intrigued about such a story because it linked two things that have long interested me – the right to die, and the looming pandemic of Alzheimer’s.  In fact, it seemed like a clear message to get the lead out and write about it.  And as if the message needed reinforcing, later that same day I had an experience that seemed coincidental at the time, and made the dream eerily prophetic in hindsight.

That afternoon, while driving to an appointment, my favourite Belgian spotted our neighbour Sophie walking along the road to the next village, a book tucked under her arm.  Although we hadn’t seen much of her in recent months, we knew she had been diagnosed with Alzheimer’s, and he was surprised to see her out alone.  When he stopped to ask if she was all right, she said she was on her way to meet her husband.
  
Unconvinced of her explanation, FB called me to ask if I could come and pick her up. 
Sophie didn’t blink an eye when I turned up.  Just in case she had the story right, I drove her around for a little while looking for her husband.  She chatted easily and issued a constant stream of almost expressionless directives, every short phrase with the same arc of inflection and always ending with my name.  Be careful at this corner, Deborah. Watch your speed, Deborah. Turn left at this intersection, Deborah.  You drive smoothly, Deborah.  Finally it seemed like the best thing to do was leave a phone message for her husband and go back to my house to wait for his call. 
   
It was a cool afternoon: while the kettle boiled, I built up the fire.  Sophie commented on how well it caught: You make a good fire, Deborah. Oh that’s funny, I laughed, because my FB and I once had a ridiculous argument about the way I had laid the fire, not bothering with the small bits, and of course it didn’t take properly. He wanted to teach me how to do it in Boy Scout fashion and didn’t believe me when I said I knew all about the proper way to set a fire.  I’ll tell him on Wednesday that you know how to make a good fire, Deborah. (Sophie played boules every other week with a group that included FB, and if her dementia had robbed her of her ability to calculate the score, her enthusiasm for the game was unaffected).

When I set the tea tray down, she eyed the oatmeal cookies sceptically: They don’t look like anything a French person would eat, Deborah. I wasn’t offended: Sophie had a fine reputation as a sophisticated cook, and did not suffer inferior food with diplomacy. The back of the kitchen cupboard yielded a box of iconic French biscuits, but when I returned with them, Sophie was already into the second cookie. These are superb, Deborah. I’d like the recipe, Deborah. All told, she ate fifteen of them.

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