Organ shortage – opposing views and potential solutions

There was an article in the NY Times a few days ago discussing the organ shortage and giving some proposals (article here). I meant to blog about it, but my life has been pretty busy at the moment so I haven’t gotten around to it. However, Sigrid Fry-Revere of the Cato Institute wrote about the particular article today. Says Fry-Revere:

The organ shortage can only be solved by increasing, not decreasing, the control people have over the disposition of their organs. Only an increase in liberty, not a restriction of liberty, has any chance of solving the organ shortage. New and innovative ways to motivate individuals to donate, including the option of compensation for donation both in the case of deceased and live organ donation, are what we need, not new ways to take organs without people’s consent.

One option Brody discusses is donation after cardiac arrest. There is nothing wrong, in principle, with retrieving organs after cardiac arrest, but what defines death and when to give up on a patient are not decisions that should be motivated by a need for organs. It is never appropriate for a doctor to alter how he treats one patient in order to provide an organ to save another patient. Just last month, a San Francisco transplant surgeon was charged with three felonies for allegedly hastening the death of a patient in an attempt to harvest his organs.

When she says “taking organs without people’s consent” she’s referring to an opt-out system. We sign our drivers licenses when we want to donate organs, but in some countries you must ‘sign your card’ when you don’t want to donate your organs. Basically it’s as if the state owns your body when you die, hence the restriction on your rights (or your family members who also may not want your organs donated). An opt-in situation like we have is preferable rights-wise, but obviously there is this massive organ shortage with people dying everyday or getting so sick that they can no longer undergo an operation even if an organ becomes available. That’s why Fry-Revere suggests compensating people or family members for their organs – you still own them, but now there is an incentive for more people to donate when they die (or in the case of kidneys, possibly when they are still alive).

The most common criticism I hear against this suggestion is that it “unfairly targets poor people”. That is, if you offer a financial incentive poor people will be more likely sell their organs because they’re strapped for cash. I’m not really sure why people think this, for several reasons. First, I would argue that the people who are most harmed by organ shortages are poor people, who tend to have poorer health in general (i.e. more likely to have diabetes and thus more likely to have kidney disease, or more likely to have high blood pressure and have kidney disease). If poor people are more likely to have conditions that place them on waitlists, then it seems that allowing people to pay for organs (or their insurance, medicaid, medicare) would be most beneficial to poor people. I think that insurance would cover the procedure, because if a good match can be made and the patient treated earlier, it likely saves money in the long run.

Second, there are lots of clinical trials right now where you are compensated for your time that you could argue target poor people, but they don’t. For instance, all around my campus there are fliers to participate in vaccine trials, asthma studies, etc and get paid decent amounts. Poor people don’t sign up for these, college students do. But any time someone mentions “organ sales” I don’t hear people complaining that it unfairly targets young male college students. I understand that a vaccine trial is probably not as risky as donating a kidney, but both still entail a risk, so why do we compensate one group for the risk and not the other?

I think if organ sales were ever legalized, that you wouldn’t see a huge increase in live persons donating kidneys, but would probably see an increase in cadaver donations – perhaps compensation would take away some of the taboo. Maybe someone would agree to donate because they know their family could use the money to cover the cost of their funeral, or pay off any remaining medical bills (or maybe they were kind of leaning towards donation, and the compensation convinced them to donate just so they can benefit someone else). I don’t see why this should be a problem, or why it is so controversial. It’s a solution that allows for more organs (and probably better immunologic matches), more people to be treated before their quality of life becomes poor, and does not infringe upon the ownership of your body. I think at the very least we should try it out on a small scale, so that if any problems do occur we can learn from them before launching it nationwide. Do you disagree, and if so why?

To read Sigrid Fry-Revere’s article, click here.

Sen. Larry Craig – deny deny deny

I guess the Senator now regrets his guilty plea…cause…ya know…he didn’t do anything wrong. His behavior was not inappropriate, and he is not gay. (note excessive sarcasm) To be honest, his behavior wasn’t “gay” as much as it was simply disgusting – I certainly know gay men that wouldn’t be caught dead engaging in such bathroom-stall behavior. Perhaps he should have instead said “I’m not gay…I’m just a pervert who picks up men in public restrooms.” His denial of any wrongdoing is funny – it’s almost like if he repeats it enough times he might actually start to believe it to be true.

I give him a week before he blames it on an alcohol or drug problem and enters rehab to be ‘cured’.

Crazy closeted and suppressed republicans. What will they do next….(more anti-gay legislation is my guess!)

Source

Obesity is not a ‘public health’ issue

Flu epidemics, SARS outbreaks, multi-drug resistant infections, etc – these are public health issues. Obesity is not. Flu is contagious and can easily pass from person to person, leading to serious injury or death in susceptible patients (i.e. elderly). It mutates, and can thus transform into a more dangerous strain and have the potential to kill quickly on a large scale if not controlled. Obesity is not contagious – you can argue that environment plays a role (hence the recent NEJM article about how obesity is “spread” through social circles), but ultimately most obesity can be prevented through actions of the individual. Eating in moderation along with physical activity does the trick for most, although of course there are hormonal imbalances and other health issues that may make it more difficult for a certain percentage. The term ‘public health’ has been led along a twisted path for so many years that it has lost its meaning, and is used to scare people and make hasty (and poorly constructed) policy decisions.

Why am I drawing attention to this distinction? Because a panel recently compiled a report called “F as in Fat: How Obesity Policies are Failing in America,” and has called for the government to formulate a national strategy for controlling obesity, essentially comparing it to a flu epidemic (side rant – “epidemic” implies the rapid spread of something infectious, thus obesity fails to qualify as an epidemic). Short of physically holding people’s hands to drag them to grocery store and pick out healthy food, or poking them with a cattle-prod to get them to exercise, I’m not sure what will a national strategy will accomplish. People know the food pyramid – this stuff is drilled into our heads in elementary school. They know they should exercise, and they don’t. The author mentions environmental problems that inhibit our ability to take action, such as suburban neighborhoods without sidewalks. I call BS on that. Almost every suburban neighborhood I’ve ever lived in had no sidewalks, and I still exercised. They are paved, after all, providing a suitable surface for walking, running, or even riding a bike. Most homes aren’t built on a busy highway, so traffic is not much of an issue. You don’t need a fancy gym membership to exercise (although those are nice if you can afford them).

The author also mentioned dangerous urban environments. I don’t think most urban areas are dangerous. I don’t have a statistic to back up this claim, but I live in the heart of a city right now and feel safe walking and running by myself in most areas during the day. Still, I acknowledge that there are neighborhoods in urban areas that are indeed very dangerous, and may make it difficult for people to feel safe walking around. I have a different solution for that, namely a change in our policy towards illicit drugs. The drug war has not worked to end, let alone diminish, drug usage in this country. Most urban violent crime seems to be associated with gang activity (and thus related to drug activity), so a change in strategy here would probably eliminate that problem, and create a safe neighborhood where citizens may freely roam. A committee debating obesity from a government office will have little impact in this regard.

The report also states that the “strategy of focusing on personal responsibility is failing.” Personal responsibility would not fail if people have sufficient incentives to take action. For me, as a medical student, learning about every possible disease (even though I know many are rare) is enough to make me paranoid about staying healthy. For someone else it might be looking good in a swimsuit, or feeling confident, or being able to walk a mile with their child without getting out of breath. But my guess is that those incentives don’t work for most people. Money, however, usually does. I knew of an insurance company at my last university that offered significant premium discounts (10-15%) for customers who agreed to live a healthier lifestyle. This included moderate exercise, no smoking, and weekly or biweekly phone calls from a nurse to check in and keep them on track. It is my opinion that we should be focusing on those kinds of incentives (or coming up with new ones), rather than continuing to publish government-approved guidelines or develop yet another “task-force” to evaluate the scope of the problem. New ideas are good and should be implemented first on a small scale to test their success – a bloated government program is a fail-proof way to ensure the status quo for a long period of time, and usually inhibits any real change.

Via CNN – “Report: National strategy needed to fight fat

To read the entire report, click here (fair warning, it’s 120 pages long, and misuses “epidemic” 37 times)

The “controversy” continues over Quick Clinics

Bob Vineyard over at Insureblog has a good take on the growing use of quick clinics (I blogged about this a few days ago). I put controversy in giant quotes because the only people who seem to think it’s controversial are a few physician groups. You don’t really see consumer groups getting all worked up over it, because the clinics tend to be great for consumers – quick treatment for minor ailments, all at a low cost. Bob and I completely agree that the hoopla and controversy is a bit like the “pot calling the kettle black.” You can check out his post here.

Katrina hospital deaths, records released

Or at least some of the records have been released, according to CNN. In case you’re not familiar with this story, it involves the question of whether patient deaths that occurred at Memorial Hospital in the aftermaths of Katrina may have been due to drug overdoses administered by doctors and nurses. The state wanted 5 medical experts to testify that up to 9 patients were homicide victims, but it is unclear whether the grand jury ever had the opportunity to hear those experts.

I don’t know the details of the situation, but my guess is that even if the state has 5 medical experts to testify that the doctors and nurses killed those patients, the defense could present their own medical experts to the contrary. For instance, one of the families hired their own investigator to look into the death of their 90 year old mother. I don’t know the health status of that woman, but at 90 years old in a hospital with no electricity and dirty flood water flowing both around and through the building, it seems likely that there could be other things contributing to her death besides excessive morphine.

I guess I feel torn about the situation – on the one hand I feel like those patients and their families deserve an investigation into why they had dangerous (or even deadly) levels of morphine in their system. On the other hand, I feel like the deplorable conditions and levels of stress that the doctors and nurses were working with at the time may have caused them to take actions they wouldn’t do under normal situations – actions that perhaps do not equate to criminal intent. Maybe they did administer lethal doses (purposefully or accidentally), but maybe those patients were suffering (they were all on the acute care floor) and the staff had no idea when help would arrive. It’s easy to look back in hindsight and say “you shouldn’t have done this”, but I think those of us who weren’t there have no idea what those patients, doctors, and nurses were going through. Will a full investigation take this into account, or will it only look at what should have occurred? It’s such a sad situation all around. Any thoughts?

CNN – “Medical experts never testified in Katrina hospital deaths

Is Fidel Castro dead?

Rumors are circulating that the dictator is dead. Obviously there have been rumors in the past about this, but could it be true this time? Perez Hilton, Cuban-American and famous (infamous?) celebrity gossip blogger says US officials are planning a press conference to announce that Castro is dead. Granted, he’s a gossip blogger, but he seems to be fairly accurate with other stories and has connections in odd places. If it’s true, will the Cuban embargo be ending soon?

Perez says “Castro is dead

Update (not much of one), but the Babalu blog is also posting about this – South Florida Law Enforcement is on alert, as are the Coast Guard and Border Patrol. It may still be a rumor, but one that people are taking seriously.

Update #2 – Perez now says an announcement will be made at 4 pm EST

Update #3 – they may have pushed back the announcement to wait until rush hour is over in Miami…definitely need to keep safety in mind

Update #4 – Though Babalu claims to have”numerous sources in numerous branches of US agencies” who have confirmed Castro is dead, it’s almost 8pm EST and no official announcement yet…perhaps it is just another rumor?

Mitt Romney unveils a new health care plan

And its got some good points, such as minimizing the restrictions states have on what counts as “insurance.” Most states have some pretty hefty regulations, such as requiring insurance to include chiropractic services or alcohol/drug treatment programs (some even mandate coverage for acupuncture). It’s not that I don’t think those services are useful for some people, but it’s silly to require everyone to purchase plans that include something many will never use – it drives up the cost of insurance premiums thus making insurance out of reach for many people.

Stuart Altman, a health economist, says that Romney has “run away from the Massachusetts plan.” It may be a very different plan, and it is likely that some will criticize this change in strategy, but Romney’s goal in both instances is to increase access to health care. Personally, I think this new plan has a greater chance for long-term survival and positive change than the Massachussetts Plan – the old idea was an attempt at patching a broken system (requiring people to purchase insurance), while this is more of an attempt of fixing the cause of the problem (looking at ways to lower the cost of insurance so more people can afford it). It will be interesting to see what else he has to say about health care along the campaign trail.

NY Times – “Romney to Pitch a State-by-State Health Insurance Plan

Michael Tanner of Cato – “Romney Abandons RomneyCare

Surprise – Retired people still have sex

I can’t believe this is news. I wasn’t going to write about it, but it seems like everywhere I look there is an article about the study published in the New England Journal of Medicine that found people to be sexually active well into their 60’s and 70’s. I guess I just have a different perspective as a medical student, but I am well aware that people do not become asexual beings once they hit 65. There isn’t some magic switch that flips to “off” once you start collecting social security or qualify for Medicare. Does anyone else think it’s weird that this is news? Maybe I’m the weird one for not being surprised.

NYTimes – “Many Found Sexually Active Into the 70s

Reuters – “Seniors want sex – and they get it, study finds

AP – “Survey: Seniors Have Sex Into 70s, 80s

CNN – “Study: Seniors having more sex than you think

Walk-in “Quick Clinics” controversial

There’s a good (short) article via Reuters discussing the use of these walk-in clinics, which are usually found at grocery stores or pharmacies. To some people they’re controversial, and perhaps it’s no surprise that one of the groups concerned with the use of the clinics is the American Medical Association. Ah, yes…the AMA.

The article mentions the AMA passing resolution a few months ago “asking state and federal authorities to investigate whether there was a conflict of interest in drug-store chains that both write and fill prescriptions.” Now, I have no problem with investigating conflicts of interest, but it’s a bit ironic that a group such as the AMA is pointing their fingers at walk-in clinics and not themselves. What better example of a potential conflict of interest than a physician who receives undisclosed perks from drug companies and then prescribes those drugs? To be honest, I don’t have strong feelings regarding whether physicians should be allowed to receive food/(small)freebies/etc from drug companies so long as they are honest and disclose these things. I should also take this moment to point out that the AMA doesn’t represent all, or even most physicians – only about 25-30% of physicians are members of the group.

Still, I checked out what their website had to say about these walk-in clinics, and there’s some entertaining stuff (well, actually it’s kind of sad…but I prefer to laugh at the absurdity rather than cry). For example, the AMA says that:

“Store-based health clinics must use standardized medical protocols derived from evidence-based practice guidelines to insure patient safety and quality of care.”

Now, you might not think this is laughable, but it is when one considers that many doctors do not adhere to so called “standardized medical protocols derived from evidence-based practice.” There will always be patients who do not benefit from such standards, because every patient is unique. However most patients do benefit from such standards which is why they are “standards”, but again – why point the finger only at the quick clinics and not also at the physicians they represent? From the AMA website:

“Store-based health clinics must establish protocols for ensuring continuity of care with practicing physicians within the local community.”

Have regular health clinics and hospitals ensured continuity of care yet? Didn’t think so. Again, says the AMA:

“Store-based health clinics must establish appropriate sanitation and hygienic guidelines and facilities to insure the safety of patients.”

This one seems so obvious that it’s a bit silly they feel the need to point it out. Or is it? Maybe not when one considers the research that estimated about 2 million patients a year acquire an infection from their hospital stay, and up to 90,000 will die as a result. Bottom line – I don’t have a problem with the AMA recommendations per se, but it’s a bit like the pot calling the kettle black. To me it comes across as the AMA only looking out for their own interests (and by that I mean the salaries of their members) instead of what is in the best interest of the patient. They’ve also lobbied hard to get these clinics under the supervision of a physician, which defeats the affordable part of the experience. I have no problem with leaving Registered Nurses in charge – I’ve had clinical visits with RN’s on a few occasions, and they are certainly competent to deliver the level of care required by many people visiting these clinics. If they can’t provide the care needed, they refer out to a physician. My guess is that if for some reason a person visiting this clinic didn’t feel like they were receiving appropriate care, they would stop going and instead find another clinical setting where their needs are met. But considering the success these clinics have achieved thus far, they seem to be operating appropriately.

Reuters article on walk-in clinics “Clinics in US retail stores bring controversy

AMA website excerpt

What do video games and public health have in common?

One (the video game) has been used to predict possible scenarios of real life disease outbreaks. Sound a bit strange? It started back a few years ago when the popular game, World of Warcraft, had a digital virus spreading amongst its players. From a 2005 article describing the situation:

The plagues started on September 13 after Blizzard updated the game to include, among other new content, a dungeon known as Zul’Gurub. In the heart of that dungeon sat Hakkar, an in-game demon, that cursed any characters who attacked it with Corrupted Blood, a damaging curse that spreads from player to player.

The disease would have not spread from the original dungeon but for the efforts of griefers. The online roleplaying game equivalent to terrorists, griefers would teleport their characters to inhabited areas or used their pets as plague carriers to spread the disease to the general population of a server, according to postings on various community sites.

So it probably would not have been an epidemic if it weren’t for some malicious individuals using their pets to spread the disease. Still, Nina Fefferman, a medical epidemiologist at Princeton University, found inspiration in the scenario (or just a lot of useful data?). Instead of placing the blame on the ‘griefers’ (aka terrorists), Efferman attributes the spread of the virus to “the stupid factor,” something she apparently hadn’t considered before.

“Someone thinks, ‘I’ll just get close and get a quick look and it won’t affect me,'” she said.

“Now that it has been pointed out to us, it is clear that it is going to be happening. There have been a lot of studies that looked at compliance with public health measures. But they have always been along the lines of what would happen if we put people into a quarantine zone — will they stay?” Fefferman added.

“No one have ever looked at what would happen when people who are not in a quarantine zone get in and then leave.”

Ah…human stupidity…now a (new) factor in epidemiological studies. While I certainly can’t argue that it’s something that should be included in her analysis, I’m not sure if a video game world is completely applicable to real life (though I know some people who get way too involved in their games and start talking about it as if it’s real life). In World of Warcraft it seems, based on the little I’ve read, it was a group of individuals responsible for most of the outbreaks. I understand that there is always the possibility of some crazy nut trying to intentionally infect people, but I question to what degree that would happen in real life where there is also then the possibility of infecting friends and loved ones in the process (not to mention the death is…well…real). Plus in the game the characters could teleport themselves…last time I checked we didn’t have that ability, which I imagine would slow the spread of the virus. Regardless, it’s always difficult to model what would happen in real life…I’m not an epidemiologist -I just think it’s cool that video games are influencing real research. Perhaps we have yet to discover the deep wisdom of Super Mario Bros. and other games…

Reuters article on Fefferman and the ‘stupid factor’

Article discussing 2005 World of Warcraft virus outbreak

Quite possibly the most original marriage proposal

And creative (oh wait, that’s the same thing as original isn’t it? anyway). This guy put a lot of effort into surprising his significant other:

Via the Friendly Atheist

Miles Levin, 18, has passed away

I wrote about Miles a few weeks ago under the title “Brevity of Life,”after following his personal CarePage for the past few months. Miles had a rare form of pediatric cancer that he had been fighting, and after exhausting all treatment options, gracefully accepted what was to come. So it was with sadness that I read upon the blog today a note from his family, indicating that he passed away. They write:

This is the update you’ve been dreading: Miles’ earthly body has left us….early this morning. This is the day we’ve been dreading since June of ’05, and fearing it would come and now it has. We did everything humanly possible to arrest this disease. Our efforts were not enough. There are no interventions currently available that could have produced a different outcome. Hardly a comfort….Talk about destiny, G-d’s plan, purpose, anything you want, but the fact is that our boy, our beloved son and brother, was snatched from us, and it hurts. We knew it was coming, yet we’re shocked. We knew it was coming, yet we’re unprepared. We knew it was coming, yet it feels unreal. We knew it was coming, but we hate it.

I’ve never met Miles, but he still managed to have an impact on me. It is sad when someone dies of ‘old age’, but to die before that feels much more than sad…it’s tragic – like they were pulled from this earth before their time. My thoughts and condolences go out to the family of Miles, the many friends he made in his short but meaningful life, and the many strangers who, like me, found inspiration in his story that he so graciously shared. The family has requested that any who wish to honor Miles do so by making a contribution to the “UJF Miles Levin Fund,” described as a “newly established tax exempt fund designed to support existing efforts to combat pediatric cancer as well as providing our family a vehicle to create new directions in patient care”:

UJF – Miles Alpern Levin Fund
P.O. Box 2030
Bloomfield Hills, MI 48303
Attn: Susie Feldman

Miles Levin, whose blog inspired thousands, dies” – Detroit News, 8/19/07

Whatever life we get is bonus” – Anderson Cooper 360 blog with Miles Levin as guest columnist, 5/9/07

Pharmaceutical companies and the doctors who work for them

Dr. Ed of Abducens Nucleus has posted Part 2 of his series “Sick, Sicker, and Sicko,” this time discussing some of the problems in the British NHS. There’s some good points over there, including how fewer Brits see medicine as a good career choice, hence the country is relying very heavily on foreign graduates (which can be dangerous for the health care of the countries from which they’re borrowing, in addition to their own system which depends on the constant influx of foreigners). Dr. Ed then goes on to discuss medical innovation in the US, and includes the following:

Sicko also fails to mention the name of Dr. Maurice Hilleman, an American whom we should all know about. He invented 8 of the 14 vaccines routinely given to young children that save about 8 million lives per year. His measles, mumps, and rubella (MMR) vaccine protects children against three diseases with a devastating legacy. Ironically, his death came less than one month after the Centers for Disease Control and Prevention announced that rubella had been eliminated as a health threat in the U.S.

Perhaps the reason the public doesn’t hear much about Dr. Hillman is because he spent most of his career at pharmaceutical giant Merck where he was able to convert his research into life saving products that benefit children world-wide. And to acknowledge Dr. Hillman’s achievements would be acknowledging the contributions of his employer to world health.

This brings up an interesting part of the health profession, specifically the general distrust many physicians (and often the public) have for pharmaceutical companies. I frequently hear the argument that drug companies can’t be trusted, because all they care about is making a profit…that they would sacrifice patient safety if it meant a few extra dollars in their pocket. I’m not here to say drug companies are perfect, as there have been heavily publicized incidences where they failed to disclose certain side effects from their products, but to say they would put profit above safety seems a bit far-fetched. It doesn’t take a genius to realize that if they injured or killed all of their customers, they wouldn’t have anyone left to purchase their goods. Or if you prefer to view them as profit-hungry bastards, if they injure a few people the public generally hears about it and the company’s stocks and sales fall…hence it is in their best financial interest to help, not hurt, people.

Dr. Hillman is a perfect example of the public good that comes from these companies, and it’s a shame few know of him. As Dr. Ed says, to acknowledge his achievements would mean you would have to admit that drug companies (and the docs that work for them) actually contribute greatly to our health – something many health professionals hesitate to admit.

Part 2 of “Sick, Sicker, and Sicko”

Does anyone like the Yankees?

I saw this and just couldn’t resist posting…love thy neighbor…unless they’re a Yankees fan:

Image and video hosting by TinyPic

I don’t really care much for baseball (I enjoy going to the occasional game but don’t follow rankings or teams), but even I know that no one, aside from people of NY, like the Yankees. Of course now I hear the Red Sox aren’t winning any fans across the country, so maybe they will redirect baseball fan hatred away from the Yankees and towards themselves? Time will tell. Regardless, the above bumper is hilarious.

Source

REAL ID really won’t stop terrorism

There’s an article today on cnn.com discussing the privacy concerns over the federal REAL ID act. I basically agree with many of the concerns, including whether the massive databases needed to support the national ID will be safe, the possibility of massive infringement on privacy, not to mention the easy accessibility of your data to a talented hacker (or government official):

EFF says on its Web site that the information in the databases will lay the groundwork for “a wide range of surveillance activities” by government and businesses that “will be able to easily read your private information” because of the bar code required on each card.

The databases will provide a one-stop shop for identity thieves, adds the ACLU on its Web site, and the U.S. “surveillance society” and private sector will have access to the system “for the routine tracking, monitoring and regulation of individuals’ movements and activities.”

The civil liberties watchdog dubs the IDs “internal passports” and claims it wouldn’t be long before office buildings, gas stations, toll booths, subways and buses begin accessing the system.

But no one seems to address something else that concerns me. The main point of these identity cards is to prevent terrorism. Says Homeland Security Secretary Michael Chertoff:

“It is simply unreasonable to expect our border inspectors to be able to detect forgeries on documents that range from baptismal certificates from small towns in Texas to cards that purport to reflect citizenship privileges in a province somewhere in Canada.”

Even if we could get rid of forgeries (which we can’t, because they will always exist to some degree), it wouldn’t matter. Has everyone forgotten that the 9/11 hijackers entered this country legally using Saudi Arabian passports and US visas? Don’t infringe upon my privacy and security on the (false) pretense of preventing terrorism.

Source

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