All medical journals these days feel the compulsion to be high-minded, but none is as high-minded as the Lancet. It is as if the editor had taken lessons both in moral philosophy and rhetoric from Mr. Pecksniff himself.
Mr. Pecksniff, you may remember, was the preposterous hypocrite in Dickens’ Martin Chuzzlewit, who introduces his daughters, Charity and Mercy, by adding “Not unholy names, I hope?” As Know thyself was inscribed over the entrance to the temple to Apollo at Delphi, and Abandon hope, all ye who enter here over the entrance to Dante’s hell, so Mr Pecksniff’s words, Let us be moral, must be inscribed over the entrance to the offices of the Lancet, figuratively if not literally
In the week before the airliner of Malaysian Airlines, taking many AIDS doctors and activists from Amsterdam to Melbourne for an international conference on AIDS, was shot down over the eastern Ukraine, the Lancet published a statement called the Declaration of Melbourne, a typically sickly and nauseatingly unctuous statement of ethical principles. It began by saying something that, if not a lie exactly, was certainly not a truth:
We gather in Melbourne, the traditional meeting place of the Wurundjeri, Boonerwrung, Taungurong, Djajawurrung and the Wathaurung people, the original and enduring custodians of the lands that make up the Kulin Nation, to assess progress on the global HIV response and its future direction, at the 20th International AIDS Conference, AIDS 2014.
This, of course, is the purest 21st Century Pecksniffery; and unless the signers of the declaration, photos of whom looking extremely self-congratulatory accompany the article, can each and severally explain in what sense the Djajawarrung are the custodians of the lands on which the city of Melbourne is built, I suggest that they be banished to the outback for five years to live as pre-contact Australian Aborigines lived.
One of my first medical publications was on the nocebo effect, the unpleasant symptoms patients may suffer as a result of being made aware of potential side-effects of a treatment they are about to receive or a procedure they are to undergo. Thus patients who were having a lumbar puncture were either told or not told they might suffer a headache afterwards; and lo and behold, those who were told that they might get headaches duly got headaches while those who were not told didn’t.
On the whole, as an article in a recent edition of the Journal of the American Medical Association points out, doctors are well aware of the placebo effect, that is to say the good that their treatment may do patients by means of mere suggestion, but have little awareness of the opposite nocebo effect, the harm that their treatment may do their patients by mere suggestion.
The nocebo effect poses an ethical dilemma for doctors, say authors of the article. On the one hand, doctors are supposed to do their patients no harm; on the other, they are supposed to be open and honest with their patients about the potential harms of drugs and other treatments. The dilemma is this: foreknowledge of those harms can harm some patients. Should the need for honesty trump the ethical injunction to do no harm?
Is there ever any good news without bad? Good and bad seem to be inextricably locked in a Hegelian dialectic, or perhaps Manichaean struggle would be a more accurate way of putting it. For example, tuberculosis became the captain of the men of death, the white plague, between the seventeenth and the nineteenth centuries. Then it began its long decline, accelerated by the discovery of the first effective anti-tuberculous drugs. Then, just as large numbers of people became more susceptible to tuberculosis because of the spread of the human immunodeficiency virus, the germ of tuberculosis developed resistance to the most effective drugs against it. It seemed that the disease might once more become what it had been not so very long before. But then, for the first time in 40 years, a new anti-tuberculous drug, bedaquiline, was developed by the pharmaceutical company Janssen. Good news has not retained the upper hand for very long, however. An article in a recent edition of the Lancet suggests that bedaquiline is not the answer to Mankind’s prayers, at least where tuberculosis is concerned.
The distinction between what the law permits and what the law enjoins is often blurred. An absence of proscription is sometimes mistaken for prescription. The more the law interferes in our lives, the more it becomes the arbiter of our morality. When someone behaves badly, therefore, he is nowadays likely to defend himself by saying that there is no law against what he has done, as if that were a sufficient justification.
The recent Supreme Court decision in the cases of Burwell v. Hobby Lobby Stores and Conestoga Wood Specialties Corp. v. Burwell illustrates the difficulties when two or more rights clash irreconcilably. The complex issues involved were the subject of an article in a recent edition of the New England Journal of Medicine. The matter is still far from settled. It seems to me likely that the Supreme Court will one day reverse itself when its philosophical (or ideological) composition has changed.
The two corporations were owned by strongly religious people. Corporations of their size were enjoined by the government to provide their staff with health insurance which would cover contraceptive services. However, some contraceptive methods violated the religious beliefs of the owners of the companies. Did the companies have the right to except these methods from the policies that they offered to their staff (who, incidentally, numbered thousands, many of whom would not be of the same religious belief)?
In principle medical research is supposed to result in unequivocal guidance to doctors as to how to treat their patients. As often as not, however, the waters are muddied as much as cleared. Two papers in a recent edition of the New England Journal of Medicine about atrial fibrillation and the cause of stroke illustrate this. It has long been known that people with a clinically-detected chaotic heart rhythm called atrial fibrillation (AF) have an increased incidence of stroke by embolism; and likewise that no cause of such stroke can be found in up to 40 percent of patients who suffer from one. Their strokes are called cryptogenic. The two papers addressed the question whether, if you monitor patients with cryptogenic stroke for long enough, some or many of them will turn out to suffer from AF. This is important, because it is generally agreed that, in patients with clinically detected and symptomatic AF, anti-coagulation reduces the subsequent risk of stroke. AF, however, is not an all or none phenomenon. Some people suffer it continuously, but others only occasionally and for only a few seconds at a time. The additional risk of stroke in the latter is unknown, but is an important question because the anticoagulation designed to reduce the risk of stroke is not itself without risk, including that of another kind of stroke, the haemorrhagic kind. In other words, the risk caused by treatment could outweigh its benefits.
If the future were knowable, would we want to know it? When I was young, a fortune teller who predicted several things in my life that subsequently came true predicted my age at death. At the time it seemed an eternity away, so I thought no more of it, but now it is not so very long away at all. If I were more disposed to believe the fortune teller’s prediction than I am, would I use my remaining years more productively or would I be paralyzed with fear?
In a recent edition of the New England Journal of Medicine a question was posed about a 45-year-old man in perfect health (insofar as health can ever be described as perfect) who asked for genetic testing about his susceptibility to cancer, given a fairly strong family history of it. Should he have his genome sequenced?
A geneticist answered that he should not: to have his entire genome sequenced would lead to a great deal of irrelevant and possibly misleading information. But if the family history were of cancers that themselves were of the partially inherited type – more factors than genetics are involved in the development of most cancers – then the man might well consider having the relevant part of his genome, namely that part with a known predisposing connection to the cancers from which his family had suffered, sequenced.
This is not a complete answer, however. Two obvious questions arise: is additional risk clinically as well as statistically significant, and if the risk is known can anything practicable and tolerable be done to reduce it? There is no point in avoiding a risk if to do so makes your life a misery in other respects. You can avoid the risk altogether of a road traffic accident or being mugged on the street by never leaving your house, but few people would recommend such drastic avoidance.
Pressure to control the consumption of tobacco has grown in tandem with the pressure to liberalize the consumption of marijuana. Perhaps this is not a paradox in the most literal sense, but it is certainly very striking. The yin of prohibition, it seems, always goes along with the yang of permission.
An article in a recent edition of the New England Journal of Medicine discusses the forthcoming tussle between what it calls Big Marijuana – the commercial interests, analogous to Big Tobacco, that will inevitably grow if marijuana ever becomes as accepted as tobacco once was – and the public health authorities. For while the smoking of marijuana does not yet cause anything like as many health problems as tobacco or alcohol, it would do so if its use were as general as the use of tobacco or alcohol. A little statistic that was published some time ago in the Lancet caught my eye: the French police attribute 3 percent of fatal road accidents to intoxication with cannabis and 30 percent to intoxication with alcohol. If, as seems likely, ten times as many Frenchmen drive drunk as drive stoned, marijuana is as dangerous as alcohol where driving is concerned.
The authors of the article point out that commercial growers and marketers of marijuana are likely, given the chance, to resort to all the techniques and obfuscations employed by the tobacco companies. They will minimize the harms done by marijuana while trying to increase the concentration of the very substance in their product that does the harm. The concentration of tetrahydrocannabinol (THC) in modern cannabis plants is already much higher than it was when hippiedom first struck the western world; Uruguay, where the cultivation and sale of cannabis has recently been legalized, is attempting to control the strains of cannabis that can be sold, with what success remains to be seen.
As long as men have experimented upon animals to gain knowledge of physiology or pathology there have been others who have decried the practice. Among them was Doctor Johnson, who said of vivisection that “if the knowledge of physiology has been somewhat increased [by it], he surely buys knowledge dear, who learns the use of lacteals at the expense of his humanity.”
Doctor Johnson argued that the cure of not a single medical condition had been discovered by the use of animal experimentation, and even if that is no longer the case there are nevertheless those who maintain that the benefits of animal research are small by comparison with their cost in the suffering of sentient beings that such research entails.
Two authors in a recent edition of the British Medical Journal, one of them an eminent epidemiologist and the other a sociologist, attempt to answer the question of whether or not animal research is a boon to medicine. Their conclusion is that it is much less so than is commonly supposed, and in some cases it is actually harmful. Since the only possible moral defense of vivisection is that it promotes medical advance, it should be stopped if it does not.
The authors point out that, according to a survey of medical scientists who perform animal experimentation, more are motivated by a desire to advance knowledge or careers than by a desire to help suffering humanity, and are actually rather indifferent to the practical use or otherwise of their work.
This is perhaps just as well, at least for their own peace of mind, because the practical value to patients of most animal experimentation is nil. This is for more than one reason.
Internet discussions usually descend into abuse within a few postings. Whether this is because people these days are less polite and restrained than they used to be, or because the internet allows them to publish their first reactions without the time to cool off that older means of communication entailed, I do not know; but the fact is that those who take part in such discussions seem to confuse insult with argument and are seldom able to keep to the point for very long.
Doctors, if the internet discussions that follow articles that appear in the New England Journal of Medicine are anything to go by, are better than average. Often, indeed, though not always, they employ rational argument. Perhaps there is something to be said after all for a long and rigorous education.
Not long ago there appeared an article in the NEJM throwing doubt on the wisdom and even the ethics of screening by mammography for early cancer of the breast. A Swiss commission examined the evidence for the benefits and found none, or some so slight that it hardly counted. The best estimate they could come up with was that mammography saved one life from breast cancer per 1000 women aged 50 who underwent screening, but that the all-cause death rate in the screened and unscreened was practically the same. Not only did many screened women undergo unnecessary operations and much radiotherapy for false positive results, but those who offered the screening were little more honest than second-hand car salesmen, in effect preying on the women’s complete misunderstanding of the supposed benefits of screening. Women believe that even with screening they are twenty times more likely to die of the disease than in fact they are; and they overestimate the benefits of screening by eighty times.
In the circumstances, then, the Swiss panel suggested that screening by mammography should be stopped forthwith.
Shortness of breath is a very unpleasant sensation and people with chronic obstructive pulmonary disease (COPD) have it chronically. It is not something that you can ever get used to, breath being so essential to life, and the disease worsens relentlessly; without medical attention one dies slowly of suffocation. That is a horrible way to die. Though COPD will become less common in time, thanks to a reduction in smoking (except in Colorado), it is still the third most common cause of death among adults in America.
As yet there is no cure and perhaps there will never be one, short of lung transplant; but it has been reported many times in the medical press that statins, drugs taken to reduce the risk of heart attack among the otherwise susceptible, ameliorate the symptoms and reduce the frequency of acute exacerbations.
Patients who have COPD and are taking statin drugs to reduce their risk of heart attack or stroke have been thought to experience fewer acute exacerbations of the disease and as a consequence to live longer. There is biological plausibility to this observation, for statins have an anti-inflammatory effect and exacerbations of COPD are caused by infection and its consequent inflammation.
If a Martian were to land on earth to study humanity, one of the things that would no doubt surprise him about our race is the pleasure it takes in contemplating its own extinction by various catastrophic means: the crash into earth of a giant asteroid, climate change or the spread of new, virulent and untreatable diseases, especially caused by viruses that emerged from the African jungle.
Of all the viruses to have emerged of late, Ebola is the most frightening. It comes in several varieties of different virulence, with (according to a recent article in the New England Journal of Medicine) death rates from a “low” 40 percent to over 70 percent. Among monkeys the death rate can be 100 percent.
Before Ebola there was Marburg, so named because it was first recognized among laboratory workers in Marburg, Germany. This virus is spread from fruit bats to monkeys to humans, and I happened to be in Rhodesia (as it was then still called) when there was an epidemic there of the disease and 33 percent of the patients died. I remember the reaction in the hospital between panic and pride that it should be in the eye of a world-publicized storm. The question on everyone’s mind was whether it could spread on a large scale from Africa to Europe and North America. Could the virus escape its ecological niche?
I remember the written response of the senior doctor in the prison in which I worked to an editorial in the British Medical Journal lamenting the difference between health care in prison and health care in the “community.” Yes, he replied, where else in the country but in prison could everyone get to see a doctor within an hour of complaining of something?
I thought of this as I read an article recently in the New England Journal of Medicine about Hepatitis C infection and the American correctional system.
About 3 million Americans are infected with the Hepatitis C virus, mainly because of having shared needles in intravenous drug abuse, but also through transfusions before blood was screened for the virus. Those who are tattooed have two or three times the average rate of infection.
Ten-to-fifteen percent of cases of untreated infection (among males) will go on to get cirrhosis of the liver, and of them an increasing proportion will develop liver cancer as the years go by. Hepatitis C infection is now the largest single cause of the need for liver transplants.
Sometimes the New England Journal of Medicine reads like a journal of failed bright ideas. I do not remember ever having read of so many failed trials of treatment as I have recently, but perhaps that is a sign of increasing scientific honesty. After all, it is as important to know what does not work as what does, especially when what does not work is very expensive to administer.
Septic shock is a condition of dangerously low blood pressure brought about by serious infection. About 750,000 cases a year are treated in the United States alone, with a death rate above 20 percent, that is to say at least 150,000 people die of it each year. This is a number well worth reducing.
More than a decade ago the results of a trial were published in which it was shown that aggressive treatment according to a pre-arrange protocol could reduce the death rate from septic shock by about a half. In those days (medicine 10 years ago seems that of a bygone era), the death rate in septic shock was much higher than it is today, which may in part explain the success of that trial compared with the failure of a more recent trial published recently in the NEJM.
One of the things that medical practice teaches the observer of human nature is that no behavior is so bizarre that humans are incapable of it and will not indulge in it. Indeed, they often seem to take delight in inventing new forms of destructive and self-destructive conduct to assert their freedom from the dictates of reason and good sense. I have not been entirely immune from this tendency myself.
Among the stranger patterns of behavior that doctors encounter is that of parents, overwhelmingly mothers, who deliberately exaggerate, make up, or physically induce symptoms in their young children so that they are investigated, often extensively, by doctors. The first two mothers whom I ever encountered who did this put blood in their child’s urine and interfered with thermometers in order to make it appear that their child was suffering from fever.
An article in a recent edition of the Lancet reviews what is known about this very odd and dangerous conduct (6 percent of children whose mothers induce symptoms in them are eventually killed by them, and 25 percent of them have siblings who have died in suspicious circumstances).
How common is this behavior? The article reviews the various estimates. In part it is a matter of definition, which is why the estimates vary between 2 and 89 per 100,000 children. This variation alone suggests a dimensional rather than a categorical phenomenon. An Italian study found that 0.5 percent of children seen in a pediatric clinics were the victims of factitious illness reported or induced by their parents. The authors do not speculate on variations in prevalence in time or between cultures, which might give a clue as to the possible causes of this conduct. The data are simply insufficient for them to comment.
There are few phrases more dangerous in medicine than “it stands to reason,” because what stands to reason may in fact not be a good idea, however brilliant it may once have seemed. This is because reality is always more complex than our theories about it; grey is theory, said Goethe, but green in the tree of life.
Perhaps the greatest single intellectual advance in the medicine of the last century was the realization that “it stands to reason” is no reason at all; everything must be studied in the light of experience. There was a good example of this necessity in a recent edition of the New England Journal of Medicine, which studied the effect of giving patients doses of aspirin or clonidine before and after undergoing non-cardiac surgery.
One of the most serious and feared complications of such surgery is heart attack, especially as the age at which people are operated on has increased. There are good theoretical reasons for believing that either aspirin or clonidine, or both, given peri-operatively might reduce the rate of heart attack in the first month after operation. Aspirin prevents the blood platelets from sticking to one another and the lining of the blood vessels, agglomeration of platelets being one of the mechanisms of heart attack; clonidine blocks the activity of the sympathetic nervous system whose overactivity is thought to be another such mechanism. Therefore it stands to reason, if anything does, that making the platelets less “sticky,” or the sympathetic nervous system less active, before, during and after operation might reduce the rate of post-operative heart attack. But does it?
A large trial was conducted in 135 hospitals in 23 countries, comparing the rates of heart attacks of people given aspirin, clonidine or placebo before and after operation. 10,010 patients were recruited in all, and the rate of follow-up was so high (99.9 percent) that it resembled the results of a Soviet-era election. Surprisingly, more than 40 percent of the patients were already taking low-dose aspirin prophylaxis when they entered the trial; but they were treated in exactly the same fashion as their peers who were not on aspirin.
One of the few laws of political science is that when governments make mistakes, they tend to be whoppers. Luckily for them, the public’s memory is short, and the outrage of today soon declines into the apathy of tomorrow.
From several articles published in a recent edition of the British Medical Journal, it appears that many governments around the world, including those of Britain and the U.S., may have made such a mistake in stockpiling billions of dollars’ worth of anti-flu medications, bought principally from Roche, the largest pharmaceutical company in the world as measured by capitalization.
First the governments overestimated the virulence of the new flu epidemic the drugs were supposed to counter, no doubt a forgivable mistake in the circumstances; but then it stockpiled the supposedly anti-flu drugs on the basis of inadequate evidence. It took published studies at face value without apparently realizing that the drug companies had withheld a great deal of data – 150,000 pages of it, as it turned out. When, after what seems like a rear-guard action to prevent it, the drug companies released all the data, re-calculation showed that the drugs were not quite useless, but had practically no value from the public health point of view. At best they reduced the duration of symptoms by a few hours and in some cases prevented the development of symptomatic disease. But they also caused serious side effects, and neither prevented deaths nor serious complications nor the rate of hospitalization. They did not prevent the spread of the infection either.
If something is either essential or good for the health, surely more of it must be good for you? Such at any rate is the reasoning of half the American population who, between them spend more than $30 billion on dietary supplements, that is to say $200 a head per annum. All things considered, these supplements must be pretty safe, unlike prescription drugs, for few people die or have serious side-effects from them. Whether they do any good, other than as placebos, is another question entirely of course.
According to an article in a recent edition of the New England Journal of Medicine there are 85,000 different supplements and combinations of supplements on the market, meaning that each of them sells, on average, approximately $375,000 worth per year. Given the popularity of some, this must mean that many are in a very small way of business indeed. It is the job of the Food and Drug Administration to monitor the safety of all these preparations: a task, one might have supposed, quite beyond the capacity of even the largest bureaucracy.
Not all the supplements are safe. One, called OxyElite Pro, caused hepatitis and even liver failure, first spotted by a liver transplant surgeon in Honolulu. It was used by body-builders to “burn off” fat, and it is isn’t difficult to find people on the internet who mourn the fact that the product has been withdrawn from the market, despite its potentially dangerous side-effects (one person died).
Dietary supplements do not undergo the rigorous testing, either as to efficacy or safety, that pharmaceuticals undergo. The author of the article points out that many supplements contain newly-devised amphetamine-like stimulants, anabolic steroids, untested chemical analogies of Viagra and various antidepressants, and weight-loss substances that have already been banned from the pharmaceutical market.
Nearly half a century ago, in 1965, the Rolling Stones wrote a song called Mother’s Little Helper. The words went:
Kids are different today, I hear ev’ry mother say
Mother needs something today to calm her down
And though she’s not really ill, there’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day…
And if you take more of those
You will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way
Through your busy dying day…
The pill was valium (diazepam) and the yellow pill was 5 milligrams – as it still is. White is 2 milligrams and blue is 10.
The song was not great poetry, perhaps, but for pop music it was prescient pharmacovigilance, the epidemiological study of the adverse effects of drugs: though strictly speaking overdoses of diazepam are not dangerous. Many thousands of people have taken overdoses of diazepam in attempts to kill themselves with it, but few have succeeded unless they took something else with it.
However, it has long been known that diazepam and other similar drugs cause falls in the elderly, and such falls are often the precursor of death. It has also been suspected that, by some unspecified mechanism, diazepam (and sleeping draughts of all kinds) promote death.
A paper in a recent edition of the British Medical Journal compares the death rates of primary care patients who were prescribed diazepam-like medicines and hypnotics with those who never were prescribed them more than once (they excluded patients who had been prescribed them only once because it was possible that they had never taken them, which was unlikely if they were prescribed them twice). The authors compared the records of 37,000 of the former with 63,000 of the latter. They attempted to match them for such variables as age, social class, sex, and medical and psychiatric history. They followed the patients for an average of 7.6 years.
Good and bad news often go together, for what is good news for some is bad for others. Shareholders in pharmaceutical companies that produce statins will have been heartened (no pun intended) by a paper in a recent edition of the New England Journal of Medicine in which the authors calculated that, under the new guidelines of the American College of Cardiology and the American Heart Association with regard to lipid levels in the blood, 12.8 million more adults in the United States alone would be “eligible” for (i.e. ought ideally to have) treatment with statins. In fact, very nearly half the population older than 40 ought to take them, and seven eighths of the population over 60. As a man over sixty who never has any blood tests done, my heart sinks (again no pun intended). We are all guilty of illness until proven healthy: not good news.
The authors compared the therapeutic consequences of the old guidelines with the new. In effect the new guidelines lowered the threshold for treatment. According to these guidelines, anyone over 40 with known cardiovascular disease should receive statins, irrespective of their level of Low Density Lipoprotein (LDL); while anyone with a level of 70 milligrams per decilitre or more and who has diabetes or a statistical risk of a heart attack of more than 7.5 percent within the next ten years should also receive them.
Taking a rather small sample of adults over 40 from the National Health and Nutrition Examination Survey whose blood lipids were measured and extrapolating it to the U.S. population as a whole, the authors conclude that, if the new guidelines were put into practice rather than the old, 14.4 million adults in the U.S. who would not have been “eligible” for treatment under the old guidelines would now be “eligible” for it, while 1.6 million who would have been “eligible” under the old guidelines would no longer be “eligible.”
Editor’s Note: Dr. Theodore Dalrymple has been contributing thoughtful pieces on medicine, culture, and politics to PJ Media for a number of years. This is the beginning of an attempt to collect and organize some of his writings on similar subjects. Here is an assortment of 10 articles weighing in on perpetual medical controversies.
A moment’s reflection is all that should be necessary to convince anybody that our passions are not necessarily engaged by public controversies in proportion to the numerical or statistical importance of the question in hand. The debate over euthanasia and physician assisted suicide (PAS) is deeply impassioned everywhere; but not even the most enthusiastic advocate of euthanasia supposes – at least not yet supposes – that the question will ever affect other than a very tiny percentage of people.
The fact is that man is an animal that quarrels over symbols, and euthanasia is as much a matter of symbolic as of practical importance. How else are we to explain the fact, cited in an article in a recent edition of The Lancet about the new Belgian law extending the benefits of euthanasia to children, that there have been dozens of bills before the Belgian parliament desiring either to extend or to limit the scope of the current euthanasia legislation?
Reading the article and the articles to which it was linked, I came across two statements, one startling and the other importantly revealing. The starting fact was the following:
Recent studies have shown that the proportion of deaths that are the result of euthanasia or PAS in Oregon, USA as a whole, and The Netherlands, are 0.09%, 0.4%, and 3.4%, respectively.
Assuming this to be no misprint, why should the rate of physician-assisted suicide be more than four times higher in the United States as a whole than in Oregon, which is one of only four states (with a total of only 5 percent of the U.S. population between them) to permit it? Is it under-reported in Oregon? Is it carried out surreptitiously and illegally elsewhere? Are all the figures so inexact as to be virtually bogus? And if they are bogus, what does that tell us about the whole matter?
Another question is why there should be nearly forty times as many deaths by euthanasia and PAS as there are in Oregon. Is unbearable end-of-life suffering forty times more frequent in Amsterdam than in Portland? This is prima facie most unlikely. The pattern of disease in most western countries in very similar, and both in Oregon and the Netherlands cancer is by far the most common cause of requests for easeful death. Is there something sinister in the disparity?
When I was young enough still to consider myself rational, I was irritated by patients who tried any remedy in desperation to save themselves from their fatal disease. I have long since mellowed and when an acquaintance of mine with glioblastoma, a rapidly fatal brain tumor, decided recently to go to India to try Ayurvedic medicine, all I could do was wish him luck – sincerely so. After all, the scientific medicine — which he would continue to take while there — offered him little enough hope, a few months at most. (This case, incidentally, illustrates an important point: alternative medicine, so called, is not generally alternative, it is additional.)
Two trials of a very expensive monoclonal antibody, bevacizumab, in glioblastoma, published recently in the New England Journal of Medicine, make disappointing or even dismal reading. This antibody is directed at vascular endothelial growth factor that promotes the growth of new blood vessels; glioblastoma is a tumor particularly rich in new blood vessels, and so it was hoped that by preventing them from forming, tumor growth would either be prevented or at least slowed. Early results were promising but as has so often been the way in the history of medicine, early promise is not fulfillment of promise.
In one trial, for example, 637 patients with this terrible tumor were randomized to conventional treatment plus placebo and conventional treatment plus bevacizumab. Although the latter had a slightly longer period free of progression of the tumor, their overall length of survival was not increased, and indeed they suffered so many more side effects that the overall quality of their lives was worse. The patients taking bevacizumab survived on average 15.7 months; those taking placebo survived 16.1 months. The authors of the paper end:
In conclusion, we did not observe an overall survival advantage first-line use of bevacizumab in patients with newly diagnosed glioblastoma. Furthermore, higher rates of neurocognitive decline, increased symptom severity, and decline in health-related quality of life were found over time among patients who were treated with bevacizumab.
This makes rather odd the concluding words of an editorial that accompanies the trials in the Journal:
Finally, it is worth noting that despite its limitations, bevacizumab remains the single most important therapeutic agent for glioblastoma since temozolemide. Ongoing and future trials will better define how and when it should be used in this population of patients for whom so few treatment options currently exist.
Clearly the viewpoint of the oncological researcher is not that of the sufferer of the disease: he is looking far into the future, while the poor patient (all the poorer if he has to pay for his drugs) is thinking rather less far ahead.
Modern medicine’s ability to save life – to keep people alive who would once have died – gives rise to an increasing number of ethical dilemmas. An article in a recent edition of the New England Journal of Medicine discusses the case of Quelino Jimenez, a Mexican illegal immigrant who was employed as a construction worker in Chicago. He had a fall that rendered him tetraplegic; after emergency treatment to stabilize his condition, and some time in the hospital, he was repatriated against his will to Mexico, where, aged 21, he died because of a lack of medical care.
Jimenez, like the majority of the 11 million illegal immigrants in the Unites States, was uninsured. The law already prescribes that hospitals receiving Medicare funding must provide emergency care to anyone in need of it, without discrimination as to legal or insurance status. However, they are not under obligation to provide, nor will they be reimbursed for providing, long-term care for those who need it. Looking after tetraplegics is expensive and consumes much time and effort. Hospitals will therefore be anxious to transfer them (and the costs) elsewhere.
It is an elementary principle of medical ethics that doctors are not permitted to sort patients into deserving sheep and undeserving goats when providing treatment for them: they are supposed to do their best for everyone, prince or prisoner. The best for Quelino Jimenez was certainly not to be returned to conditions in which, only too predictably, he would be medically neglected.
The problem with banks, say their critics, is that they privatize their profits but nationalize their debts. But this is perfectly normal behaviour for human beings: did not Bastiat say that the state is the means by which everyone seeks to live at everyone else’s expense? How many people seek the freedom to behave as they wish while expecting others to pay for the adverse consequences? Moral hazard has become our way of life.
An article in a recent edition of the Journal of the American Medical Association advocates the distribution of a drug called naloxone to heroin and opioid addicts. Thousands of such addicts die of overdoses of these drugs each year in America, and naloxone is an effective antidote to them that reverses their effect. More than half of the 38,000 deaths from overdose in the United States are from prescription drugs, and 16,000 of them from prescribed opioids, more than from illegal heroin.
The article cites evidence from Wilkes County in North Carolina (the county with the third highest rate of deaths from opioid overdose in the country) that the distribution of naloxone to addicts has almost halved the death rate from overdose. Not all those whose lives were saved were either prescribed opioids by pain clinics or addicted to street heroin: they were foolish friends or acquaintances of either of these types of people who had been induced to try their drugs.
What is completely lacking in this article is any wider perspective. The people who pay for the naloxone are often not the people taking heroin or opioids; one might have supposed that those who can afford street heroin, at the very least, could also afford to buy their own naloxone. If they do not care enough for their own safety to do so, it can be argued that no one else should care – unless, of course, they are deemed, like Ophelia, to be “incapable of their own distress.” But if so, why should they be left free to take the heroin in the first place? In other words, like bankers, addicts want to be free to indulge in their own excess but want someone else to pick up the pieces when the excess leads to a smash.