Dr. Kevorkian and the Hippocratic Oath

A couple of weeks ago, I attended my son Mikey’s graduation from medical school in St. Louis.  During the pre-commencement ceremony, the newly minted M.D.s recited the Hippocratic Oath.  (Faculty were also invited to recite the Oath, and while most did, some noticeably declined.)

As I listened to the Oath, I anticipated the famous phrase, “Do No Harm,” but it never was uttered.  After the ceremony, I read the Classic translation of the Oath and confirmed that there was no such phrase, but it did say, “I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”  By digging a little deeper, I learned that the Original translation of that phrase was, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”  Close enough.

The next provision in the Oath relates to Dr. Kevorkian, who died earlier this week:

• “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.”

In a lengthy obituary on Kevorkian, the NY Times said, “But his critics and supporters generally agree on this: As a result of his stubborn and often intemperate advocacy for the right of the terminally ill to choose how they die, hospice care has boomed in the United States, and physicians have become more sympathetic to their pain and more willing to prescribe medication to relieve it.”

In 1997, Kevorkian’s advocacy resulted in Oregon becoming the first state to authorize physicians to prescribe lethal medications to help
terminally ill patients end their lives. In 2006 the United States Supreme Court held that Oregon’s Death With Dignity Act protected a legitimate medical practice.

Kevorkian assist in 130 suicides in the 1990s, but the last one resulted in a conviction for 2^nd Degree murder and confinement until his release in 2007, after promising to never assist another suicide.  His story was the subject of a 2010, award-winning HBO movie (“You Don’t Know Jack”) starring Al Pacino.

I suspect that Dr. Kevorkian was ahead of his time.  In the not distant future, physician-assisted suicide spread from Oregon to the rest of America.

 

The Sunday Book Review #31 – The Da Vinci Code by Dan Brown

Several years ago, my son Bobby loaned me a book of CDs – The Da Vinci Code.  The book sounded interesting, and although the thought of listening to someone read a book to me seemed a bit juvenile, I agreed to give it a try. 

Apparently, my heart wasn’t invested in the idea because the CDs languished on my bookshelf for years even though I had made several boredom-inducing, 24-hour drives to North Dakota.  This past week, however, as I prepared to make a 15-hour drive from San Antonio to St. Louis for my son Mikey’s graduation from medical school, I noticed the CDs and decided that I would never have a better opportunity to test he concept, especially since I would be driving solo.

Count me as doubly satisfied – with the concept and the book.

The Da Vinci Code consists of 13 CDs and 16 hours of reading.  Because the reader, Paul Michael, reads at a deliberate pace, I don’t understand how he can read a 454-page book in only 16 hours.  It certainly seems to take me a lot longer than that to read a full-sized book.  An additional advantage of listening as compared to reading is that listening is much easier.  Usually when I read a book for more than a couple of hours, I find myself wanting to take a break.  Not so when listening to a book.  I listened for many hours at a time and actually had less of a problem with my mind drifting away.  In fact, the hundreds of miles of driving drifted away while I remained focus of the mystery of Da Vinci’s code.  And finally, it was nice hearing the multitude of French words being pronounced correctly as opposed to hearing me mangle them.

Regarding the substance of The Da Vinci Code, I agree with the millions of readers who have made it the best-selling English-language novel in the 21^st century.  Its characters are captivating, its plot is fascinating, and its context – politics in religion – is a subject that has always interested me. 

Most people don’t think of politics and religion as mixing – i.e., politics is dirty compromise, while religion is pure principle.  Of course, an institution like the Roman Catholic Church would not have survived as long as it has if it weren’t political and pragmatic, but the Church tries to keep that stuff behind the scenes.

I remember decades ago seeing a mini-series titled The Thorn Birds, with Richard Chamberlain, and that was my first exposure to the politics and money that are involved in a successful career within the Church.  In many ways, service in either government or religion is controlled by the Golden Rule – i.e., he who has the gold rules.

The Da Vinci Code doesn’t spend much time on corruption by money, but rather it shows how far religious people will go to ensure their success – kind of like Richard Nixon getting caught up in the urge to win at all costs.  Author Dan Brown places the Church in a crossfire between the conservative Opus Dei and liberal secularists. 

Although the 2003 book and the 2006 movie were huge commercial successes, the book was savaged by the critics.  They say it was poorly written and, more importantly, gave grossly distorted depictions of factual institutions, such as Opus Dei and the Roman Catholic Church.  Much of the plot revolves around the possibility that Mary Magdalene was actually Jesus’s wife and that she bore him a child after his crucifixion. 

As an irreverent iconoclast, I enjoy reading (er, listening) to stuff like that.

Texas ban on texting while driving

I previously mentioned that the Texas legislature was considering a ban on texting while driving (TWD).  My son Mikey responded by asking if he would still be able to surf the internet while driving.  Good question, so I promised to read the law.

By doing a little research, I learned that several texting bills have been filed, but only one has been passed by the House and forwarded to the Senate – H.B. 243.  The relevant language in this bill provides:

• “An operator may not use a wireless communication device to write or send a text-based communication while operating a motor vehicle unless the vehicle is stopped.

In its original version, H.B. 243 prohibited sending or receiving texts, but it was amended to apply only to sending texts despite a proponent’s argument that it would be an “administrative nightmare” for police to have to determine whether a driver was reading or typing.  As a practical matter, I think police officers would need to examine the cell phones for evidence of a violation, and I don’t think they have the right to conduct that type of search. 

Incidentally, while reviewing legislation in other states, I noticed that some states ban sending or receiving texts, while others take a broader position by prohibiting “distracted driving,” which would include texting.  That broader sort of law makes a lot more sense, but Texas legislators have rejected it in favor of a narrow law that may be virtually unenforceable. 

Thus, the answer to Mikey’s question is that, even if the Texas bill passes the Senate and becomes effective in September, he not only can surf the internet while driving, but also can receive and read texts.  And I’m not sure how the police would ever be able to charge him with texting while driving unless the police officer is in his back seat looking over his shoulder.

The ultimate objective, however, is not to arrest people, but to change behavior, and as one police chief explained a municipal ban on texting:

• “You know, the criticism has been, ‘Officers won’t be able to enforce it, people will say they were dialing the phone,’ McManus said. “But here’s the bottom line for me: If a law is passed, there are going to be people who obey it simply because it’s on the books. There are folks out there who will obey a law because it’s on the books. There are others who will probably not. But the fact of the matter is, I believe there will be fewer people texting, which will make our roads safer.”

Sunday book review #22 – White Coat, Black Hat by Carl Elliott

In the past few months, books about the medical profession have moved onto my reading list for a couple of reasons:

• Although ObamaCare is on life-support, America will need to replace it with something, and no one seems to know what that replacement should look like.
• My son Mikey will become an M.D. next month, and I want to understand what he’s getting into. 

I was hopeful that White Coat, Black Hat would improve my understanding of modern medicine, and I wasn’t disappointed.  The book, which is subtitled Adventures on the Dark Side of Medicine, is a current look at bioethics.  

Bioethics is the study of controversial ethics brought about by advances in biology and medicine.  The author Carl Elliott, who has a medical degree and a doctorate in philosophy, is well qualified to expound on the subject.  The book consists of six chapters, each of which discusses an issue that troubles Dr. Elliott. 

Chapter One – titled The Guinea Pigs – concerns the subjects of medical research.  Most of the chapter focuses on (a) the economics involved in getting people to submit to becoming guinea pigs and (b) the sometimes inadequate protections to ensure their safety.  The chapter included an interesting history on a group of WWII conscientious objectors who volunteered to (a) gargle pneumonia-infected sputum, (b) wear lice-infested underwear to contract typhus, (c) allow mosquito-filled boxes to be strapped to their bellies so that they would get malaria, and (d) be placed on semi-starvation rations for six months in order to understand how to treat malnourished citizens in liberated countries in Eastern Europe.  Talk about taking one for the team.

Chapter Two – titled The Ghosts – concerns the fact that most academic papers are authored by ghostwriters working for pharmaceuticals, with the role of the academic person limited to editing and signing.  This practice is widely accepted because the writing is so technical, with no real pride in authorship.  Dr. Elliott seems more concerned that these ghosted papers play a large role in the professional advancement of the academic person working under the adage of “publish or perish.”

Chapter Three – titled The Detail Men – concerns the role of the pharmaceutical representative.  The term “detail” is a historical term that means to give a doctor information about a company’s new drugs with the aim of persuading the doctor to them.  I was especially interested in the discussion of whether the detail man’s freebies are effective – the possibility of which doctors reject out-of-hand because there is no possibility “that physicians are so weak and lacking in integrity that they would sell their souls for a pack of M&M candies and a few sandwich and doughnuts.”  Of course, as the author points out, the pharmaceuticals wouldn’t be giving away things if the gifting wasn’t effective, and studies confirm this.

Chapter Three also contains a description of the improved reporting on each doctor’s prescribing habits.  This information is widely available to pharmaceutical reps, and this prevents doctors from inaccurately assuring the reps that the doctors are or will prescribe the rep’s drugs.  

Chapter Four – titled The Thought Leaders – concerns the role played by key opinion leaders (KOL) “in managing the discourse around a given product – a discourse that is equal parts scientific study, commercial hype, and academic buzz.”  As I was reading this chapter, I started thinking about Malcolm Gladwell’s book, The Tipping Point, and sure enough, the author inserted a quote from The Tipping Point – “Ideas and products and messages and behaviors spread like viruses do.”  This chapter focuses on the pharmaceutical practices for identifying, cultivating, and harvesting of KOLs.  The author does not use the analogy of a whore and her pimp. 

Chapter Five – titled The Flacks – concerns the role played by the public-relations person.  The author uses the analogy of the Volkswagen flack who was charged with selling a $70,000 luxury VW Phaeton to VW constituents who generally are “creative, environmentally sensitive liberals who are concerned about social justice… read the NY Times, listen to NPR, and shop at Whole Foods.”  Not that there is anything wrong with any of that. 

I especially enjoyed the author’s discussion of branding – no, not branding of the drug, but branding of the patient’s disease.  Among the flack’s techniques:

• Portray the condition as common, yet underdiagnosed.  For example, clinical depression. 
• Destigmatize a shameful condition.  For example, urge incontinence becomes overactive bladder.
• Direct-to-consumer (DTC) advertising.  The AMA reversed its opposition in 1992, and in 1997 the FDA relaxed its warning requirements that had essentially precluded TV ads. 

Chapter Six – titled The Ethicists – discusses the author’s fear that ethicists like himself are becoming whores to the pharmaceutical industry.  Much of the chapter concerns institutional review boards (IRBs), which are “the committees responsible for overseeing the ethics of medical research in the United States.”  Historically, IRBs have been academically based, but now many are for-profit, and they seem plagued with the same conflict-of-interest that caused the rating agencies like Moody’s to contribute to America’s financial meltdown in 2007-8.

Although the book contained an Introduction and a “Coda,” there is essentially no beginning or end; only six distinct chapters.  My conclusion is that pharmaceutical industry is analogous to the energy industry in that its immense profits are being lavishly deployed to ensure that those profits keep coming in.  The difference is that the pharmaceutical industry must work with the medical profession, and maximizing profit should never become the number one objective of a profession.  But sometimes it becomes a close second.