Dying Well

My aunt died yesterday morning. I was not particularly close with her, although she had always been pleasant enough to me when growing up (I don't think I have seen her in over 20 years) and I have generally fond memories of family gatherings as a child with my mother's side of the family.

She died of metastatic lung cancer that had been diagnosed just about a year and a half ago. She initially opted for radiation and chemotherapy, but after several months of treatment with typical complications, she had decided not to try to "beat" the disease and focused on getting her affairs in order before she died. (One such complication, typical of the kind experienced by cancer patients, was that the radiation to her tumor at the top of her lung also affected her esophagus, creating ulcers that made it exquisitely painful for her to swallow, requiring her to be fed intravenously. When she understood that "curative" treatment would mean months of IV feeding, or would require "tube feeding" in which a tube would be inserted from her abdominal wall directly into her stomach to provide her with nutrition--and that all of these measures would not necessarily ensure success--that was the final straw for her.) She invited all of the female members of her extended family as well as close friends down to her place just under a year ago for a "celebration of life"; my wife and daughter, who had never met her, flew down and by all accounts it was a wonderful weekend. As the months passed she continued to do relatively well, but by the winter the tumor had metastasized to her brain, and she declined gradually over the past several months, entering into a coma less than a week ago.

During the past few months she was cared for in part by hospice workers, but largely by my other aunt, a pediatric ICU nurse who fortunately is quite familiar with caring for the sick. Other family members provided what support they could by visiting or helping financially. My mother, who had just attended her granddaughter's bat mitzvah ceremony the week before, flew down to be with her sisters until the end and say goodbye.

She died in that comatose state yesterday morning, of what I assume was uremia (kidney failure). Her body had been gradually shutting down, and her descent was peaceful. Yesterday I spoke briefly with my mother, who was not surprisingly upset to have lost her younger sister. With that understanding, I did explain to my mother that my aunt was remarkably fortunate to have died a death, virtually painlessly, surrounded by her family, in her home, and got to say goodbye to those who cared for her. They were all very lucky.

I had another aunt on the other side of the family with whom I was closer, who died about ten years ago from ovarian cancer. Almost to the end she was determined to fight the disease, and consequently suffered unbearably even when, from my point of view, it was clear that she would succumb. In the end she did die at home, but was in considerably more pain because she had not sought hospice weeks or months before when they could have helped her. She died within the same year that another woman, the mother of one of my college roommates and a woman who has come closest in my life to being something approaching a surrogate mother-figure for me, had also died of ovarian cancer. Like this other aunt of mine, she had refused to accept defeat, and the unfortunate consequence was her dying while being coded by total strangers in an ICU, and never having had the chance to say goodbye to her four children or husband.

Their deaths have gnawed at me over the years as I loved them both.

I write this not out of anger but perhaps a certain disappointment in the values that we hold that lead us to such decisions. My mother's sister, by contrast, was in an enviable position considering the hand she was dealt. She died a good death, and though I wasn't much of a nephew to her, as a doctor that is one of the highest compliments I can pay her on her passing.
--br

PS--There is more to be said about The Influenza--much more--and I hope to be back in the next few days with further observations.

Various Thoughts on The Flu

The "Swine Flu" situation is so rapidly moving that to provide commentary on the technical aspects of the disease (such as: is this year's vaccine protective against it? why do the cases in the US appear to be not as severe? when should i take Tamiflu? etc.) would be possibly outdated within hours of this post. Moreover, I assume that the limited readership of this blog is familiar with the excellent sources of information whose job it is to keep the public informed, among them the CDC and WHO websites, and in particular the NY Times site has a great page devoted to the outbreak. Thus, what follows is a scattering of thoughts about the portrayal of the outbreak, and my own reaction to what's happening.

a. I first heard about the outbreak Friday morning April 24 at my division's weekly infectious diseases conference. At the end of the meeting one of the senior clinicians informed us that there was a flu outbreak in Mexico City with an apparent new strain, and that up to 60 people were believed dead. That got me to sit up straight. True, Mexico City is (I believe) the most populous city in the world, with a population somewhere in the vicinity of 30 million people, so normally 60 deaths of any cause save Ebola in a city of that size would not seem to be such a big deal. Yet 60 deaths from flu in a short span of time anywhere is at least concerning.

Following the conference I went to my computer and sought info from The Paper Of Record, and was surprised--indeed, stunned--to see a quote from Dr. Anne Schuchat, the head of the respiratory disease division of the CDC, in the first NYT article on the outbreak. "We don't yet know the extent of the problem," she said, "but we don't think this is a time for major concern." [my emphasis] Now it is possible that Schuchat was misquoted, or quoted out of context; I certainly hope so, because this statement seemed to me wildly at odds with my gut impression of the early information coming out of Mexico: hey, this is scary! I am not the world's foremost authority on flu, but I am an infectious diseases doc, and I couldn't fathom how an outbreak of apparently lethal influenza wasn't a cause for "major concern" in a country that borders the outbreak. Within less than 24 hours, the CDC had a much different take on the events in Mexico, and within 48 hours had declared a public health emergency. Which, make no mistake, this is, even if the total number of US cases doesn't rise above 100 and nobody dies. You don't mess with the flu. (Doc Schuchat, it may be time to spruce up that résumé!)

b. There is a fine line between engendering appropriate concern and contributing to hysteria, and while the statements that I have heard from US public health officials have (except for Dr. Schuchat's initial whopper) seemed on the mark, the media sometimes--okay, often--do such a poor job of putting things into context that, when coupled with a largely scientifically illiterate public, you can't help but induce a panic. For the interested reader with 13 bucks I highly recommend Marc Siegel's book "False Alarm," which delves deeply into the mainstream media's dependence on fear-mongering as a means to keep huge segments of the public titillated, distracted, frightened and whatnot.

So far, though, the coverage has seemed reasonably good. I grant that my sources are skewed as I prefer the Times and NPR to Newsweek and "Good Morning America," but the stories have generally put the facts out, supplied the let's-not-go-overboard-but-still-let's-stay-alert quote from public health officials, and then discussed the situation either in Mexico or on the home front with requisite fretting about how this will affect the economy. There's a little obsessing as NPR, for instance, took 10 full minutes this morning to lead with the story, which may have been a bit much, but make no mistake, this is the Number One news story of the week. People do need to know it's out there and that, under worst-case scenario, they may need to be prepared to take the steps that are already well underway in Mexico (see below). Panic isn't useful; concern, however, is, and we should all be concerned about this bug right now.

c. I don't claim to know anything about the machinations of the Mexican government but thus far it appears that their public health officials know what they are doing, and President Calderón has been admirable in his swift response to the events. Given that, it hardly needs pointing out about our own government's failings during Hurricane Katrina. Mexico is experiencing the biological version of Hurricane Katrina right now, and as of now the ferocity and competence of their response has, alas, put our own national emergency response to shame (at least based on recent history, not the current situation, where it's still too early to tell).

d. To expect politicians to be political without being partisan may be expecting too much, but I saw at least one instance this week where a pol was being goofily partisan, and I saw another situation where the pols should have been vociferously partisan but appear to have left the battlefield. In the former instance, one of the Dems (I think Homeland Security Sec'y Janet Napolitano, but please don't quote me) said that the Republican holdup of HHS Sec'y nominee Kathleen Sibelius was putting the country at risk given the situation with the flu. That's just pure overstatement, especially as Napolitano herself appears to have assumed the lead role in terms of crafting a federal government response. I'm not saying that I want the Sibelius nomination held up, only that you don't want to use a real crisis for a political cheap-shot.

On the other hand, President Obama himself should have called a press conference saying that Texas Governor Rick Perry could help himself to all the Tamiflu he wants--per his request that portions of the federal Tamiflu stockpile be dispensed to Texas--if and only if he would stop braying like an ass about seceding from the Union. You wanna secede, Rick? Well, here's your first act as guv of the New Republic Of Texas: find some Tamiflu! Wishing you luck on that front.

e. One other point on the media coverage is that the media has appeared to need to give a moniker to this bug, and thus it is the "Swine Flu" outbreak. And while there is a ring of honesty in the name, it's a touch misleading. Flu biology is quite complicated but one critical point is that the virus's natural habitat is mostly humans, water fowl, and pigs--so nearly all influenza viruses are to greater or lesser degrees "swine flu." The type of virus causing all the fuss is known as H1N1, which is a strain that is "native" to humans; one of the components of the flu vaccine is an H1N1 strain. (Without going too much into detail, there are multiple types of "H" proteins, which combine with multiple types of "N" proteins, and consequently make up dozens of types of influenza, each with strain variants. The vaccine for flu is actually a combination of two of these types, the H1N1 and H3N2 types, and includes a third component of a related virus, Influenza B.)

Those are my thoughts for the moment. I would love to hear anyone else's take in the comments.
--br

The Autopsy: Still With Surprises, After All These Years

I'm not sure if there is a procedure in medicine more maligned than the autopsy. Early modern European docs, by and large our modern forbears, were peeling recently deceased people apart since the very, very early stages of the renaissance (and, if Roy Porter is to be believed in his seminal-but-goddawfully-boringly-named history of medicine, The Greatest Benefit To Mankind, it may have happened even before then), and my guess is following every major advance in diagnostic medicine, somebody declared the need for the autopsy and research in the gross anatomy lab to be finished. This was followed by defenders of the practice pointing out that our faith in our diagnostics is grounded more in hubris than in reality; fortunately through the magic of the NY Times website I can even produce evidence of such a diatribe--from 1921! The opener: "The need for a change in attitude on the part of the public toward the autopsy and the fact that the very limited number of autopsies performed [in the US] acts as a handicap in the instruction of the [sic] interne and medical students are points which are being earnestly discussed in medical circles." Nearly 80 years later, the same complaints were being made.

Nevertheless, a skeptic of the need for modern autopsies could point to a few key technologies that really have changed the playing field of diagnosis in favor of the physician in the past two decades. When discussing it with patients I refer to this technology as "looking under the hood," and it consists mainly of CT scans, MRIs, and ultrasounds (including echocardiograms, which are just ultrasounds of the heart, yet nobody calls them that, no doubt contributing to the perplexity of laypeople on medical topics). Various maladies that used to be able to hide out in the chest, abdomen and pelvis--such as, for instance, a liver abscess--avoiding detection typically light up on various scans. When coupled with the dozens of biochemical tests we now have at our disposal, it's hard to assert that we don't know what's going on when people die. So the argument goes. "I mean, seriously, back when I was a med student you didn't really know why people were dying, and you wanted to know how good your tests were to see if you got the diagnosis right on someone who died," a very senior physician once told me when dismissing the need for routine autopsies. "But now, I'd say we know better than 95 percent of the time. Anyone who says otherwise is dreaming."

Like many physicians--probably the majority of physicians who harbor any opinions about autopsies--I generally agree with this sentiment, although I heard a presentation the other day that brought me up short. While discussing kidney disease occurring in the midst of HIV infection, a colleague posted some intriguing data that just recently was published in Kidney International. The group, led by Christina Wyatt at Mount Sinai, looked at a subset of HIV-infected patients who were part of a cohort called the Manhattan HIV Brain Bank, and had agreed to undergo autopsy following their deaths. These researchers, not interested in neurological pathology, exclusively looked at microscopic slides of the kidneys of 89 of these patients. And some of their findings struck me: 4 patients had the premortem diagnosis of glomerulonephritis (not a trivial condition), while 8 were found to have evidence of it at autopsy; 1 patient with the premortem diagnosis of interstitial nephritis, but 5 had it at autopsy; no patients were found to have chronic pyelonephritis (kidney infection) prior to autopsy, though 7 cases were discovered under the microscope. Overall, while 75 of the 89 patients were found to have some form of microscopic renal pathology at autopsy, only 27 carried the premortem clinical diagnosis of chronic kidney disease.

It isn't clear to me whether or not these microscopic findings bear relevance on the actual proximal and contributory causes of death for these patients, but it is hard to dismiss the idea that they might be. At the risk of sweeping generalizations, physicians often look for the simplest, most straightforward explanation of a medical event, but this study seems to indicate that, at the cellular level, there may be many pathological events, interacting with one another and creating feedback loops that lead to a medical event (like a heart attack, or abrupt kidney failure, or a blood clot in the lungs, or a stroke, or any number of other things). If so, some, or possibly many of our diagnoses may need to come with asterisks attached.

Two caveats: one is that this study doesn't have any impact on the debate about the gross anatomy autopsy (i.e. looking at a body with the naked eye); with the accuracy of cat scans, it is still almost impossible for abscesses and tumors to "hide." Two is that HIV is a particularly complicated disease, and researchers from bedside docs to bench scientists are still trying to understand how the disease progresses--so this was a patient population most likely to yield surprising findings like this. Would you find hidden kidney pathology in, say, a breast cancer cohort? Not sure. Nevertheless, with studies such as this, the days of autopsy are, I suspect, not yet finished.
--br

With or Without Bush, the Right Wing War on Science Continues. Is it Working?

President Obama appears to be backing away from strong statements about climate change he made during he made during his campaign for the White House. One key point of the NYT article: in the recently-passed budget resolutions, cap-and-trade provisions for industry were removed from the legislation in both the House and Senate without apparent objections from the Obama administration.

There may be a degree of insider baseball to this story, which the Times goes on to discuss, the gist being that the Obama administration may unilaterally impose dramatic changes to carbon emissions through the EPA rather than having to do it through congress. But more worrisome would be that the administration, trying to pick its fights and expend its political capital carefully, is backing away from a confrontation that they believe they might lose because the public still--after nearly three decades of increasing scientific consensus!--does not quite understand or appreciate the gravity of the situation. And Obama's political opponents appear to be gearing up on this front, threatening a large-scale misdirection and misinformation campaign about global warming. From my point of view, this is part of an ongoing war against the entire process of science; if right wing leaders find the discoveries of science to be incompatible with their political goals, they simply deny it, and go to great lengths to destroy science's credibility. And it hardly goes without saying that this is bad not only for America's present, but its future as well.

Denying global warming is hardly anything new to the right wing, but it has taken a more urgent tone in the past few months. The first and most appalling example came from an op-ed by George Will in the Washington Post on February 15--less than one month into the Obama administration. Entitled "Dark Green Doomsayers," Will lays out the case that climate scientists essentially have no idea what they are doing, that they are quite poor predictors of the future, that in the 1970's scientists actually thought the world was cooling, and as a consequence most if not all of their theories shouldn't be taken very seriously. Three days later, in the midst of several scientific blogs howling about Will's column, Andrew Revkin of the New York Times wrote a "news analysis" entitled "In Climate Debate, Exaggeration is a Pitfall," and among other things included a debunking of Will's column.

It's quite clear that Revkin's column is just that--a semi-opinion column rather than a "pure" news story--but Will counter-punched the following week, getting in a couple of nice jabs at the Times for writing "meretricious journalism in the service of dubious certitudes." This was done while theoretically defending one of his most important claims, which was that "...according to the University of Illinois' Arctic Climate Research Center, global sea ice levels now equal those of 1979." Leaving aside my pedantic instinct to point out that WaPo's copy editor got the possessive of Illinois wrong, Will, in rebutting the rebuttal, screwed the pooch for a second time in less than a week. The full explanation is covered by one of Discover magazine's bloggers Carl Zimmer, and is highly recommended reading, but the short version is that Will managed to cherry pick two points of data apparently supporting his claim, but doing so in a sea of information (an apt simile in this case) casting doubt on that very claim. Moreover, Will, in the second column, never bothered to contact the author of the source information that he cited to make sure he had his facts straight, which he most certainly did not. (And, of course, he didn't even deign to defend the biggest whoppers contained in his first piece, like his claim that most scientists in the 1970's thought the world was cooling, but no matter; as I have linked before, there's a not-very-smart "gosh, why's everybody upset?" comment by the Post's ombudsman.)

By March 21, WaPo ran yet another op-ed, this time improving the discourse: Chris Mooney, a writer whose subject matter is the politicization of science, shredded Will's reasoning (if it can be called that). Since the second column, though, no further words from Will. And as Bob Somersby at The Daily Howler points out, while Mooney's op-ed was welcome news in the editorial pages of the Post, Will's column is picked up by hundreds of outlets and his influence is wide; few probably picked up the Mooney column and thus many readers of Will's two columns haven't heard the reasonable counter-argument, and heard nothing from the people most qualified to discuss the issue (like Zimmer at his Discover blog). All in all, it was not a great month for the Good Guys.

All of this is chewing on old bones, but the Times ran an article on Thursday indicating that the misinformation put out by George Will is just the opening salvo in what might be a coordinated, all-out debunk effort by right wingers before serious attempts are made by the Obama administration to tackle the climate change problem. The piece features Marc Morano, a former spokesman for Oklahoma Senator James Imhofe (for those who don't follow national politics, Imhofe is about the most pure right wing senator there is), and how he is revving up a media campaign to attack any political solutions to the climate change problem. I don't have problems with anyone of whatever political stripe trying to disseminate information on scientific issues; the problem is that Morano appears to be working in the service of a political ideology first and picking the science to suit that view, ignoring or disparaging anything that contradicts that view. Additionally, he is willing to all but lie in support of those views: one of the tastier bits in the article discusses how he posts a list of "more than 700 scientists dissent over...global warming claims" and includes one "meterologist" in the list of scientists who is not only not a meterologist (he's a local TV news weatherman), but one who is opposed to the idea of climate change "because it takes God out of the picture." Well done, Marc! Further explanations of Marc Morano's tactics and those of the global warming-deniers can be found at desmogblog.com (that's "De-Smog," if the name didn't make any sense); if interested in yet another example of the corruption of the debate on global ice melt a-la George Will, see here.

I am not a climate scientist and as such do not have the qualifications to say definitively whether climate change is or is not a valid theory. But I can see whether or not there is a consensus (there is one on global warming) and try to understand the science behind it; that's the best any non-specialist can do. Moreover, I can try to understand the motivations of those who might not want the theory to be true, whether it is or isn't. And that has been, unfortunately, the guiding theme of (for the most part) right wingers in the US for at least the last 50 if not 100 years. (Yes, the Scopes trial was prosecuted by noted left winger William Jennings Bryan, but times have changed.) If science doesn't fit in with their short-term goals, they simply deny its truth. If that ain't dangerous, I don't know what is.
--br

PS--I note, to be complete, that the Times ran a piece in its Sunday Magazine two weeks ago about a real scientist who has serious objections to global warming (Nobel laureate Freeman Dyson), though one voice of dissent to me does not suggest that we should ignore the consensus of climatologists and abandon efforts to reverse or halt climate change through public policy. There will almost never be "total" consensus on any given scientific topic (Nobel laureate Peter Duesberg believes that HIV is not the cause of AIDS, for instance; I think he's completely nutz), but in general there are just too many people who know about this stuff that say it is so, and that is good enough for me.

Two Items, Unrelated (Except for a Big Ten Connection)

a. In a quiet backwater of the news world today, there is a piece about President Obama's nomination for the director of the US Census, which bears significance on this blog's subject matter, though admittedly only in a peripheral way.

Obama's choice is a man named Robert Groves, who served as the associate director of statistical design for the Census from 1990-92. Groves, who is a professor at the University of Michigan, caused a minor kerfuffle during his tenure there for pointing out that the Census's statistical sampling methods were remarkably crude: then as now, the Census works by mailing people forms and counting the replies. This results in dramatic undercounts in areas where people are less likely to have stable, long-term addresses--places that typically vote disproportionately for Democrats. And members of the Republican party have fought against anything other than the 19th-century "head count" method ever since.

The key point here, from my perspective, is not especially about who benefits in the short run from possible changes to how the Census is administered (and there will be no changes for the 2010 census according to the AP story). What is critical is this story represents yet another area in which a war is being waged on scientists simply by virtue of the disinterested information they provide to the government such that the government will make good long-term decisions. For the most part this war has been waged by, and on behalf of, the members of the Republican party, and found its greatest and most effective expression in the machinations of the Bush administration. And though the Republican party may be in something of a retreat at the moment, its far right wing--which clearly dictates the national Party's policies--continues to oppose the entire intellectual structure that allows science to thrive, and does so with great ferocity. That is, the Groves nomination constitutes a threat not only because it might marginally diminish Republican power, but more importantly because it demonstrates a totally different way to arrange government, where non-partisan civil servants provide the best and most accurate data to policy-makers.

Or to put it another way, the reaction against the Groves nomination, which is already quite clear based on the quotes in the AP article, is of a piece with the Republican intimidation of career scientists and policy experts at NASA, the NSF, the FDA and NIH to name but a few, on subjects ranging from global warming, the extinction of endangered species, and the teaching of evolution. To this list we can now add, "how to count a sample of people properly."

b. The Milwaukee Journal Sentinel ran an article over the weekend illustrating in detail the kind of money sloshing around medical schools these days, in which Big Pharma supports the ongoing "education," if it can be called that with a straight face, of physicians. Keep in mind that what goes on at the University of Wiscosin is no different than many or even most other medical schools in the US. I have little to comment on the article other than to say, "read it." Props to the Carlat Blog for the heads-up.
--br

Lies, Damned Lies, and Statistics: Vol. 1

Mark Twain's famous quip probably has four hundred thousand instances prior to this one, but for the Billy Rubin Blog, this is Volume Number One.

Actually, the problem in this instance may not necessarily be in the statistics, just how the stats are portrayed. And the difference between one portrayal and another is the difference between a shrug and full-fledged panic.

In yesterday's New York Times there is a brief piece about a study of "near-term" infants, comparing them to those born full-term. The gospel when I was in medical school was that 32 weeks was something of a magic number--those babies who could make it to that time were believed to have no increased risk of abnormalities compared to babies who were not delivered until 40, i.e. the full term. The current study discussed by the Times article casts doubt upon that. The near-termers (born 3-6 weeks prior to due dates) were noted to have--and this is the key word--subtle differences in levels of disabilities or developmental delay. But before we get there let's trot the stats out. Assuming the research is good (which I do) both of these statements are true:

a. Near-term babies have a thirty six percent higher risk of having a disability or developmental delay.

b. Slightly more than four percent of near-term babies had these abnormalities, while just under three percent of full-term babies had them.

As you can see, statement "a" seems a good deal more troubling than statement "b," even though they utilize the same data. Interpretation is everything. And the Times does a nice job of explaining the nuance. Roni Caryn Rabin, the reporter, notes before laying down these two identical yet seemingly contradictory stats that "Over all [sic], the risk is small, and doctors emphasized that parents should not be alarmed."

The question is: will smaller print-news organizations that are likely to pick up the Times story, or the local TV media that have a habit of trying to tease viewers with the most sensational bit of a story to attract viewers to their local "Health Watch" sections of their news programs, relay the all-important subtlety that the overall risk of developmental delays and whatnot in near-term infants is still quite low?

I have my suspicions. Readers, help me--let's keep track of this story over the next week and see what play it gets, and if it becomes a sensational, 36 percent increased risk in abnormalities, New Threat To Civilization, or if it is described for what it really is. I hope to hear from you.
--br

Back In The Saddle

Thanks to the readers of this blog for their patience and forbearance during the past 2.5 weeks when no new entries came forth. I have been slammed by a vicious case of MRSA cellulitis, which happened to coincide with some nasty GI bug that claimed my entire family as victims, one by one. Only today, after nearly two solid weeks of being weak/feverish/nauseous, and in pain from the cellulitis, do I feel anything resembling the description "normal."

My illness led to two visits to the ER--two more than I have had in the past 15 years, at least when I was the patient. No, I don't have any dramatic revelations about How Different It Is To Be A Patient, and don't think I've learned anything valuable that will fundamentally alter how I approach patients as a doctor. There is one exception, however. I have long heard patients in the ER ask with some urgency when they will "go upstairs" to their hospital bed after I have completed their admission paperwork, because they can't stand staying put! I have usually shrugged, explaining that the bed situation is controlled by nurses and their staffing priorities. At least now I understand their complaint: those stretchers in the ER are unbelievably uncomfortable! Woe to those with low-back pain forced to endure a several-hour stint in an ER. My advice is to lower the stretcher as close to flat as possible and roll to one side. Not always so easy when you've got all those wires and IV lines and blood pressure cuffs attached, but your back will thank you for it.

Back in the next few days with something of substance to chew on. In the meantime, do feel free to leave "ER Horror Stories" if you wish in the Comments.
--br

Stem-Cell Ban Lifted; Is The Justification Right?

There's a touch of slippery language in President Obama's prepared remarks on lifting the stem-cell ban that was put in place by President Bush:

"[I]n recent years, when it comes to stem cell research, rather than furthering discovery, our government has forced what I believe is a false choice between sound science and moral values...this Order is an important step in advancing the cause of science in America. But let’s be clear: promoting science isn’t just about providing resources -- it is also about protecting free and open inquiry. It is about letting scientists like those here today do their jobs, free from manipulation or coercion, and listening to what they tell us, even when it’s inconvenient -- especially when it’s inconvenient. It is about ensuring that scientific data is never distorted or concealed to serve a political agenda -- and that we make scientific decisions based on facts, not ideology." (my emphasis)

Now to be clear: Billy does not disagree with President Obama's decision to lift the ban; indeed, like many of the moves of the President in recent weeks (after a very concerning sluggish start), he practically cheered himself hoarse when he heard the announcement of yet another rollback of the policies of the Bush administration.

That said, Billy isn't so sure that the metaphor of a scale of scientific knowledge on one side balanced by moral values on the other is a "false" one. Indeed, he thinks that a good number of troubling scientific research projects done are troubling precisely because they were not balanced by those very "moral values"--and many of these studies were done well into our own lives; indeed, in this decade! Billy is happy to cite such studies on request (including a doozie from a cancer journal published in 2002); in the meantime he assumes the shorthand is acceptable.

The issue, to Billy's mind, is not that there is a false dichotomy between the need for scientific knowledge and the moral values that restrict the access to such knowledge, but rather involves an argument about the moral values themselves. That is, it's not that scientists should just have their way and those with "moral values" should be trampled over in the quest for knowledge, but instead that we have to have a debate about which "moral values" will form the basis of ethical research. Billy has no desire to cede the "moral" high ground to what appear to him to be mostly religious fundamentalists. He does believe that moral values sometimes do have to put a halt to science. He just thinks that banning research on stem cells in the arcane belief that a collection of cells constitutes a human life is a poorly reasoned basis for such values.
--br

Is Pharmacology at Harvard Medical School Being Taught By Drug Companies, or Professors?

The good name of Harvard Medical School has been a bit sullied these days. The NY Times details the general ickitude in an article about a couple of bold medical students who came forward with the idea that perhaps it was not right to learn about drugs from people who made money--and one can only assume lots of it--moonlighting as speakers touting the wonders of the very drugs about which they were supposed to teach with disinterest. One choice tidbit: one of the students meekly asked a pharm professor about the side effects of cholesterol drugs, and apparently got "belittled" in reply. A fellow med student named Matt Zerden did some online checking afterward and discovered that said professor was a paid consultant to 10 drug companies, including five makers of cholesterol treatments. Bravo, future Doc Zerden and your fellow activists! The article notes that the American Medical Student Association has given Harvard an "F" for how poorly it monitors and controls the relationship between its faculty and big pharma, though its Ivy-league cousin the University of Pennsylvania got an "A." The silver lining may be that the new dean, Dr. Jeffrey S. Flier, wants to make some changes and has convened a committee to re-examine Harvard's policies. Billy's Blog promises to hope for the best and report on any changes should they become known to him.

Better still is that the Harvard student activists, while holding a demonstration to call attention to the problems inherent in such laissez-faire policies, were photographed by an employee of Pfizer in what appears to be a creepy kind of surveillance project. Senator Charles Grassley (R-Iowa), who is investigating the relationships between the pharmaceutical industry and physicians, is looking into the shenanigans. Go Chuck! (I have delivered my one endorsement for a Republican in the year 2009.)

One last recommendation for the truly interested is to check out the comments section to the main article (on Harvard's ethics issues, the first link above). The "Editor's Selections" include at least two hum-dingers, with a reasoning process that would bring a smile to Rush Limbaugh's face (see comment #11 from RichardN, Idaho, and #16 from Dr. O, Michigan). Apparently the Editors feel a need to represent letters both pro and con, regardless of how well the comments are written. The "Readers Recommendations" I find to be more telling of what a highly literate, sophisticated group like NYT readers think of the comments, and--no surprise, this--the above comments don't arouse much sympathy.
--br

Women in Medicine

Okay, I said I was going to hold off for a few weeks pending some urgent work, but I couldn't resist.

Billy has of late become a fan of the Bioethics Discussion Blog, thoughtfully led by Dr. Maurice Bernstein. A long-standing blog, one can literally scroll through several hundred discussions on various ethical issues involving modern medicine. The most recent post concerns the shifting gender demographics in the medical profession and references an op-ed in the February 25 edition of JAMA ("The Feminization of Medicine and Population Health," by Dr. Susan Phillips and Emily Austin). Dr. Bernstein provides a long quote where the authors discuss matters such as the differences in proportion of women physicians in primary care fields versus subspecialties, and concludes that this may have an impact on overall health care given that primary care fields are much more likely to be "longitudinal" in nature. (For the lay-readers, that's fancy medical terminology for "you have a long-standing relationship with your physician.") The authors conclude:

"Either way, as women increasingly enter medicine and become generalists, rather than being a liability by not working excessively long hours or abandoning parenting, the quality of the care they provide may result in improved population health.”

Billy, being the good card-carrying let's-all-sing-kum-ba-ya liberal that he is, poses no objection to the massive influx of women into the ranks of physicians. However, he does want to take issue with the reasoning that the authors use here.

Though not quite explicit, they seem to imply an argument from utility: we should all be appreciative of the "feminization of medicine" since it may result in improved population health! And Billy disdains mixing arguments about moral rightness with those involving utility. To wit: "the government should be utilized to improve the genetic stock of its people." This was one of the most common refrains heard 100 years ago by prominent eugenicists, of both progressive and conservative political leanings, and that bedrock utilitarian notion formed the basis of mass-sterilization campaigns of people who at the time were thought to be "genetically inferior" but would now be described with one very simple word: "poor." Similar utilitarian arguments have formed the basis of many if not most of the mass slaughters perpetrated on various populations throughout the 19th and 20th centuries (slavery, the Holocaust, Stalinism, the Cultural Revolution, the Khmer Rouge...have I missed anything?). Of course, no such ugly intent can be imputed to the authors of this article; my point is that the rhetoric of utility is the wrong approach to take.

Additionally, the problem that a utility-based argument poses for their cause is if it turns out that large numbers of female physicians (whether primary-care or otherwise) do not improve overall population health. Assuming this could be studied at all (of which Billy is highly skeptical), should we abandon female applicants to medical schools if we discover in study after study that female physicians provide either no benefit or even a decline in care? (In the comments section of the link, "obdoctom" asserts the latter, arguing that the takeover of OB/GYN by women in the past decade has only made patient care worse.) Billy would argue "no," that the reason why you have just as many qualified women as men admitted to medical school is because it's the right thing, and not because of some possible population benefit down the road. There may well be positive effects wrought by the change--indeed, how could there not be?--but such changes are merely a happy consequence of, and not the reason for, that change.

UPDATE: A follow-up to the know-nothingness of George Will and his poorly-reasoned articles on global warming takes place over at The Daily Howler (March 2), but if you want the aw-shucks defense of the editorial staff as to how an influential columnist could be allowed to print pure fantasy, feel free to check out the WaPo's ombudsman's column.
--br