Hospitals also face possible liability for compromising patient privacy, which is protected by Federal legislation. However, since blogging is so new, many doctor-bloggers complain that the guidelines are fuzzy. Dr Stern says that the only way to blog safely about patients is to ask for their consent. " Absent that, you're on shaky moral ground," Stern said. "The only way you can totally protect confidentiality is to not say anything." ~ Detroit Free Press, Mar 14
A controversial standard for determining death is multiplying the number of organs available in the US, but creating bioethical quandries. "Donations after cardiac death" (DCD) have risen from 268 in 2003 to at least 605 in 2006, enabling surgeons to transplant more than 1,200 kidneys, livers, lungs, hearts and other organs. "It's starting to go up exponentially," says James Burdick, who is in charge of organ donation at the federal Department of Health and Human Services.
Donation after the heart stops beating was the norm until brain death became the standard in the early 1970s. The shortage of organs has prompted a revival of the practice and the National Academy of Sciences' Institute of Medicine has declared it ethical so long as strict guidelines are followed. Organs are removed after the heart stops beating, normally at least five minutes, to ensure that the patient is really dead. The decision to withdraw care must be kept separate from the decision to donate organs.
However, some bioethicists and doctors have misgivings about all this. First of all, DCD gives the macabre impression that doctors are hovering over a body waiting for a person's organs. It can also interfere with a peaceful death and deny relatives time to grieve. Pressure could be applied to relatives to discontinue care prematurely. "It's worrisome when you stop thinking of the person who is dying as a patient but rather as a set of organs, and start thinking more about what's best for the patient in the next room waiting for the organs," says Gail A. Van Norman, of the University of Washington at Seattle.
Although the criteria sound strict, they are only recommendations. In Denver, for instance, surgeons at Children's Hospital wait not 5 minutes, but 75 seconds, before removing organs from infants. A California doctor is being investigated for apparently trying to hasten the death of a potential donor.
And if the practice becomes established, what about the future? David Crippen, a University of Pittsburgh critical-care specialist, asks, "Now that we've established that we're going to take organs from patients who have a prognosis of death but who do not meet the strict definition of death, might we become more interested in taking organs from patients who are not dead at all but who are incapacitated or disabled?" ~ Washington Post, Mar 18
ENTRUSTING LIVES TO A COMPUTER PROGRAM
Living wills are one solution to the anguish of deciding on treatment for a loved one in a coma. The patient's instructions -- theoretically -- will be followed by medical staff. But if there is no will, as is normally the case, what would they want? Writing in the Public Library of Science Medicine, David Wendler argues that a computer can outguess relatives.
After reviewing the literature, he found that patients and their relatives only agreed 68% of the time on whether to withdraw or continue treatment. However, when he applied a simple rule and asked unrelated people to make the decision, the rate went up to 78.4%. This rule is that people will accept life-saving interventions if there is at least a 1% chance of recovering their ability of reason, remember and communicate. A computer came up with nearly the same result, 78.5%.
Dr Wendler now wants to refine his computer's criteria to take into account sex, age, educational level, religion and so on. It might be able to predict a patient's wishes with an accuracy of 90%. This might relieve the pressure on relatives who have to make the difficult decision to pull the plug on a life support machine. It might also make it easier on doctors and bioethicists if they can leave life-and-death decisions to a computer. ~ Economist, Mar 15
IRAN'S LIBERAL BIOETHICS
Despite its reputation in the West for intolerant Islamic fundamentalism, Iran has relatively liberal legislation on abortion and stem cell research. Writing in the Indian Journal of Medical Ethics, two Iranian bioethicists say that Islam teaches that ensoulment takes place at 120 days after conception. This makes it possible for Iranian scientists to do embryonic stem cell research and therapeutic cloning, and for doctors to do abortions. In 2005, the Iranian parliament passed a "therapeutic abortion act", which allows abortions after a diagnosis by three experts and a confirmation by the "legal medicine organisation". Abortion is now legal during the first four months of pregnancy if the foetus is mentally or physically handicapped or if the mother's life is in danger.
According to the authors, from Tehran University of Medical Sciences, the incidence of birth defects seem to be rising in Iran. There is a preference for consanguineous marriage, which results in a higher level of defects and the age of marriage for educated women is rising, as in the West. Pregnancies after the age of 35 are now more frequent, and there is more concern about chromosomal disorders. ~ Indian Journal of Medicine, Oct-Dec 2006
THE DOWN SIDE OF THE GAY GENE THEORY
What if homosexuality is biological and not volitional, determined by genes and not by choices? Is this good news or bad news? Most frequently, gay rights supporters cite this as evidence why their lifestyle should be accepted. But biological determinism is a two- edged sword, as the Rev Albert Mohler Jr, one of America's leading evangelicals, showed this month.
Mohler has created a firestorm of controversy with an article suggesting that there may be "some level of biological causation". But his response was not acceptance, but medical treatment for the unborn foetus. "If a successful treatment to reverse the sexual orientation to heterosexual is ever developed, we would support its use as we should unapologetically support the use of any appropriate means to avoid sexual temptation and the inevitable effects of sin," he wrote in his blog. Not surprisingly, gay rights groups accused Mohler of homophobia, although he urged Christians to be understanding and charitable towards homosexuals.
Mohler's intervention in the debate was sparked by recent research which appears to show that rams with same-sex attraction can be "cured" chemically. This led to speculation that a pregnant woman whose child might be genetically disposed to homosexuality could wear a hormone patch to change his sexual orientation. ~ AP, Mar 15; www.albertmohler.com
LOS ANGELES CLINIC STARTS GAY IVF PROGRAM
A controversial Los Angeles IVF doctor is a bit more controversial now after publicising a dedicated program for gay men who want biologically related children. Dr Jeffrey Steinberg, of The Fertility Institutes, is already notorious for offering sex selection. Now he has branched out and become a one-stop shop for gay couples. He offers psychological, legal, and medical help, along with surrogate mothers and egg donors. So far he has treated about 70 gay male couples, about 30 of them from the US, and the others coming from Britain, Germany, China, Canada, Italy, Brazil and South Africa. The average cost is about US$60,000 for a take-away child.
To Dr Steinberg's surprise, three-quarters of gay couples pay extra to select the sex of their baby and only about two-thirds want boys. Steinberg is a dab hand at dealing with criticism. "This is news," he says. "It is challenging. We understand people are a little intimidates, a little frightened by it," he says. "It just takes time to get used to things." ~ Reuters, Mar 14
IS THE BRAIN DRAIN A ZERO-SUM GAME?
The threat of a brain drain of talented scientists to other countries is frequently used as a reason to support embryonic stem cell research. Now the leading journal Nature has made the counter- intuitive argument that source countries actually benefit from the flow of skilled individuals overseas. Take Britain. "According to the World Bank, Britain has more professional émigrés than any nation on Earth, but it doesn't seem to be hurting. California's research labs may be crawling with Brits, yet UK science has gone from strength to strength."
What accounts for this phenomenon? First of all, scientists aspiring to go overseas work harder at home. When they leave, they also keep up their connections. In any case, stem cell research is just a minor feature of global talent flows. The issue is greatest in Africa. South Africa has even taken steps to penalise state-trained health professionals who leave. However, according to research from the Center for Global Development, in Washington DC, "impeding the migration of skilled health professionals, by sending and receiving countries, does little to improve health systems or heath outcomes in Africa." ~ Nature, Mar 15
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Why the world's most powerful country has the second-worst infant- mortality rate in the developed world, just pipping Malta and Slovakia, is a puzzle. The usual answer to why so many American babies die before they are one year old is inadequate health care funding. But a paediatrician at the University of Massachusetts Medical School, Darshak Sanghavi, has a different idea. He believes that it is "the unintended side effect of increased spending on medical care".
The leading scientist in the Bush administration has broken with his boss over embryonic stem cell research. "From my standpoint, it is clear today that American science will be better served, and the nation will be better served, if we let our scientists have access to more stem cell lines," Dr Elias A. Zerhouni, director of the National Institutes of Health, told a Senate committee.
The co-editor of one of the world's leading bioethics journals, Bioethics, has stated that he supports reproductive cloning. Writing in his blog, Udo Schuklenk, of Glasgow Caledonian University, says that "there are no serious reasons against reproductive cloning".
Blogging has mushroomed amongst American doctors, but some health professionals worry about violations of confidentiality. Sometimes their internet diaries include harsh judgements of patients and coarse or obscene details. "One of the fundamental aspects of medicine is that patients have to feel free to tell doctors everything," said Dr. David Stern, of the University of Michigan Medical School. "They're not going to tell us everything if they're asking themselves when they come in to see their physician, 'Is my doctor going to blog about me?'"