The Schiavo case

TerriSchiavoCase230x150.jpgA number of friends have asked me why I have not blogged on the Terri Schiavo case, to which I have stolen Eugene Volokh‘s reply that “I know nothing about the Schiavo matter, and — despite that — have no opinion.”
As we have seen with the Enron case, when a case becomes as sensationalized in the MSM as the Schiavo case has over the past several weeks, battle lines get drawn politically, increasingly shrill views compete for the public’s limited attention, and wise perspectives tend to get lost in the shuffle. Bloggers can find thoughtful views — such as those of Professors Bainbridge and Ribstein — but, let’s face it, the vast majority of the public do not read blogs.
At any rate, I wanted to pass along a couple of informative articles on the Schiavo case that will appear in next month’s New England Journal of Medicine. Timothy Quill, M.D. is a nationally-recognized expert in palliative care and end-of-life issues who is a professor of medicine, psychiatry, and medical humanities at the University of Rochester, School of Medicine and Dentistry. In this article, Dr. Quill dispassionately reviews what has occurred in the Schiavo case, and then makes the following observation:

In considering this profound decision, the central issue is not what family members would want for themselves or what they want for their incapacitated loved one, but rather what the patient would want for himself or herself. The New Jersey Supreme Court that decided the case of Karen Ann Quinlan got the question of substituted judgment right:

If the patient could wake up for 15 minutes and understand
his or her condition fully, and then had to return to it, what would he or she tell you to do?

If the data about the patient?s wishes are not clear, then in the absence of public policy or family consensus, we should err on the side of continued treatment even in cases of a persistent vegetative state in which there is no hope of recovery. But if the evidence is clear, as the courts have found in the case of Terri Schiavo, then enforcing life-prolonging treatment against what is agreed to be the patient?s will is both unethical and illegal.

In the same issue, George P. Annas, J.D., the Edward R. Utley Professor and Chair Department of Health Law, Bioethics & Human Rights at Boston University School of Public Health, pens this article in which he reviews the legal precedent relating to the Schiavo case and criticizes Congress for ignoring it. In so doing, Professor Annas observes the following:

There is (and should be) no special law regarding the refusal of treatment that is tailored to specific diseases or prognoses, and the persistent vegetative state is no exception. “Erring on the side of life” in this context often results in violating a person?s body
and human dignity in a way few would want for themselves. In such situations, erring on the side of liberty ? specifically, the patient?s right to decide on treatment ? is more consistent with American values and our constitutional traditions.

Hat tip to the HealthLawProf blog for the links to these articles.

The Texas Children’s case

texas children's.gifThis HealthProfBlog post provides an insightful analysis of the legal issues raised by the decision of Texas Children’s Hospital earlier in the week to take Sun Hudson, the nearly 6-month-old who had been diagnosed and slowly dying from a rare form of dwarfism (thanatophoric dysplasia), off the ventilator that was keeping him alive. A Houston state district court had authorized the hospital’s action, and Sun died shortly after being removed from life support.

Dr. DeBakey: Health model

Dr. Michael DeBakey is Houston’s most famous physician and one of the most reknowned of the post-World War II generation of doctors who changed the way medicine was practiced in the world. But in this Wall Street Journal ($) article, Dr. DeBakey is something entirely different — a model for longevity and good health:

[L]ong a role model for physicians, [Dr. DeBakey] now can serve as a role model for another group: anyone turning the corner on what used to be called old age. In 1965, Dr. DeBakey appeared on the cover of Time magazine. He was 56. Almost 40 years to the month later, the 96-year-old remains a player in the field of medicine, his most recent article (“Kismet or assiduity?”) having appeared only last month in the journal Surgery.

Entering the room, Dr. DeBakey looked only slightly older than he did in photographs taken decades ago. Sitting down, he poured himself a cup of coffee with a steady hand. For anyone who wrestles with the health implications of caffeine, this gesture might have borne significance, except that during the two hours we spoke Dr. DeBakey barely took a sip of it. “This will be my only cup of the day,” he says, touting moderation.
His hearing was sharp; I never repeated a question. . .

His personal habits largely parallel what doctors order. He always has been a light eater, and on most days takes only one meal, dinner, often consisting of a salad. “My wife is a great salad maker,” he says. Though he doesn’t take vitamins or engage in what he calls “formal exercise,” he walks from place to place, putters around the garden and chooses stairs over elevators. He is on no medications, doesn’t drink and never smoked. His military uniform still fits him perfectly.

Interestingly, Dr. DeBakey views the key to his longevity and health to be something that the medical profession often characterizes as damaging to health — hard work and stress:

But here is what Dr. DeBakey sees as the real secret to his longevity: work. He rises at five each morning to write in his study for two hours before driving to the hospital at 7:30 a.m., where he stays until 6 p.m. He returns to his library after dinner for an additional two to three hours of reading or writing before going to bed after midnight. He sleeps only four to five hours a night, as he always has.

But isn’t stress harmful? In the Time magazine article of 40 years ago, Dr. DeBakey expressed scorn for the alleged ill effects of stress: “Man was made to work, and work hard. I don’t think it ever hurt anyone,” he said then. Now, that quote elicits a sheepish smile from him. “I was being provocative,” he says.
Although he concedes now that stress can be damaging, he also believes that work is underrated as a health tonic. “What we call stress is sometimes stimulating and can bring out the best features in our makeup,” he says, adding that no vacation spot could ever prove as relaxing for him as did the operating room. “Work can block out the unpleasant things we have to deal with every day. When you concentrate, you are not distracted by the things that are bothering you.”

My anecdotal experience with my late father — Dr. Walter Kirkendall — certainly supports Dr. DeBakey’s views. Walter worked as a professor of medicine at the University of Texas Medical School in Houston literally up to the day he died suddenly of a heart attack in 1991. Although stress arguably played a role in his sudden death, Walter’s work during his final years was a large part of what sustained him, giving him the focus and purpose of a much younger man. Walter would not have wanted to live his life in any other way.
The examples of Walter and Dr. DeBakey remind us that the motivation to excel in what we do is inextricably tied to our will to live.

An alternative to heart bypass surgery

This Washington Post article reports on drug-coated stents, which are allowing an increasing number of people to avoid having heart bypass surgery. The new generation of tiny, drug-coated metal scaffolds prop open arteries and slowly release medication that prevents the arteries from from reclogging. Check it out.

Novartis rocks medical community with $8.4 billion expansion of generic drug empire

Swiss pharmaceuticals giant Novartis AG announced over the weekend an $8.4 billion expansion of its generic drug holdings in a move that is widely viewed in the drug and medical communities as the continuation of trend toward consolidation in the generic drug sector. As a result of the deal, Novartis will become the world’s largest seller of generic drugs at a time when it is already the top seller of branded drugs. Novartis had total world-wide sales last year of just under $30 billion.
Novartis will pay $7.4 billion to buy Hexal AG of Germany and 68% of Eon Labs Inc., which are two generic-drug makers that are controlled by Germany’s wealthy Str¸ngmann family. As a part of the deal, Novartis will also launch a tender offer to acquire the balance of Eon shares for about another billion.
The generic drug industry has exploded in growth since the 1980s when U.S. law was modified to make it easier for drug companies to copy successful branded drugs. As a result, the generic drug industry became increasingly aggressive at challenging the legality of branded drug patents in court, which has often resulted in patents being overturned years ahead of the normal term.
Nevertheless, the sector has always been highly fragmented and now its profits are being squeezed by brutal price competition. Thus, these difficult market conditions are prompting consolidations in the generics business, and the Novartis deal reflects that the branded drug companies are going to be involved in the consolidation in a big way.

Second Circuit reverses “Super Size Me” lawsuit dismissal

Super Size Me is the Morgan Spurlock documentary that chronicled Spurlock’s health as he as he ate nothing but McDonald’s food at least three times a day for a month. Although certainly not a balanced treatment of the fast food industry, Super Size Me is quite clever and certainly worth watching. Last week, the film was nominated for an Academy Award in the best Documentary Feature category.
One of the criticisms of Super Size Me was that it was a transparent attempt to promote frivolous lawsuits against the fast food industry, although the onslaught of such litigation has not occurred. Nevertheless, such lawsuits received a glimmer of light yesterday from the Second Circuit Court of Appeals. In this decision, the Second Circuit reinstated part of a highly publicized lawsuit that accused McDonald’s of misleading young consumers about the healthiness of its products.
The Second Circuit’s decision concluded that the trial judge in the case incorrectly dismissed parts of the lawsuit brought on behalf of two New York children on the grounds that the lawsuit complaint failed to link the children’s alleged health problems directly to McDonald’s products. For the trial court to dismiss the case on those grounds without a trial, the Second Circuit essentially held that such a ruling could only come in summary judgment proceedings after discovery and presentation of summary judgment evidence. Thus, the decision at least opens the door a crack for the plaintiffs’ lawyers to demand in discovery from McDonald’s the type of previously secret documents regarding the company’s promotion of unhealthy products that ultimately led to a string of multi-billion dollar verdicts against Big Tobacco companies.
John F. Banzhaf III, a George Washington University professor of public-interest law who has advised plaintiffs in the big tobacco cases, is an unpaid adviser to the McDonald’s plaintiffs in this case.
Despite McDonald’s protestations to the contrary, Super Size Me has already had an effect the way in which McDonald’s promotes its menu. In early 2004, McDonald’s removed the “super size” option from the menus of its 13,000 U.S. restaurants and it began promoting a new line of premium salads. The company also began promoting milk as an alternative to soft drinks and sliced apples as a substitute for French fries in its famous Happy Meals for children.
I suspect that those apples have not competed particularly well against McDonald’s French fries. ;^)

Is your surgeon a “Nintendo surgeon?”

Following on this earlier post about video games being used as anesthetia for young patients, several of my surgeon friends, nephews, and my two sons are going to enjoy this latest finding:

Surgeons who play video games three hours a week have 37 percent fewer errors and accomplish tasks 27 percent faster, . . [based on] observation on results of tests using the video game Super Monkey Ball.

Link hat tip to Tyler Cowen, who hilariously suggests that maybe the surgeons and the patients could play each other?

The Myth of Vioxx

Dr. Rangel analyzes in posts here and here the dilemma raised by Merck’s decision to pull Vioxx from the market. Definite clear thinking. Check his thougts out.

K-rations and dieting

Ancel Benjamin Keys, PhD., the inventor of the K-rations that kept Allied troops alive and reasonably well fed on the battlefield during WWII, died last week at the age of 101.
But the greater contribution of Dr. Keys is even more interesting. As Sandy Szwarc notes in this TCS op-ed, Dr. Keys’ greatest scientific contributions are to our understanding of the human body and eating.
Inasmuch as the mainstream media in America is obsessed with dieting and a svelte figure, few Americans who read Dr. Keys’ obituary know that, over half a century ago, he conducted the soundest clinical studies ever done on the adverse effects of dieting. His findings — which have been confirmed many times since — proved that dieting can actually cause severe physiological and psychological harm, often results in people becoming fatter, often leads to eating disorders, and even increases the risk for heart disease and life shortening illnesses.
As Ms. Szwarc notes:

The extreme physical and mental effects [of restricted diets that] Keys observed led to his famous quote:

“Starved people cannot be taught democracy. To talk about the will of the people when you aren’t feeding them is perfect hogwash.”

Read the entire article.

Could you pass a maggot, please?

My late father — Dr. Walter M. Kirkendall — was a master internist who was a legend among his students for his diagnostic skills and conservative views toward use of many medicines. For one of the reasons supporting his skepticism regarding the use of clinically untested medicines, take a look at Alex Tabarrok’s post over at Marginal Revolutions on Jerry Avorn’s new book, Powerful Medicines.