Tuesday, November 24, 2009

A Worried Response To the Bishops' Directives.

Bioethicist Dr. Tarris Rosell weighs in on the new ANH directive coming out of the Catholic church:

On November 17, the U.S. Conference of Catholic Bishops voted 214-4 "to strengthen its requirement that Roman Catholic hospitals insert and maintain nutrition and hydration tubes for patients in persistent vegetative states."

The rule appears to be that all patients in vegetative states would be sustained on life support, even contrary to their own wishes or that of a surrogate, unless they already are deemed "close to inevitable death from underlying conditions." (Modern Healthcare, http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20091117/REG/311179934#)

Ever since the Terri Schiavo controversies, and Pope John Paul II's allocution of March 20, 2004, there have been rumblings of potential action of this sort by the bishops. Apparently, this is it.

Now comes the aftermath in Catholic hospitals, predicted to be anything from widespread noncompliance to what one canon law expert said could be "a whole series of Terri Schiavo cases." (Paul Danello, quoted by Joe Carson in Modern Healthcare,


Would it really matter whether the diagnosis was incurable cancer or irreversible neurological damage? Why limit this religious healthcare directive just to brain injury? Perhaps the bishops' orders will be applied more broadly than to treatment of those in vegetative states. I wonder.

What other particular situations will arise that place patients and compassionate caregivers in conflict with a blanket order from a powerful religious minority group? Will patient
s now shy away from receiving care at the faith based hospital they have known and trusted for years? Again, I wonder.

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Coalition to Pass Health Care and Stop Stupak.

For Contact Information: Pass Health Care Reform and Stop Stupak! website <http://action.stopstupak.com/content.jsp?content_KEY=3039>

Coalition Announces DC Lobby Day and National Week of Action

A broad group of
advocacy organizations from the progressive and women’s health communities has joined together to form the Coalition to Pass Health Care Reform and Stop Stupak! <http://action.stopstupak.com/content.jsp?content_KEY=3037> The coalition’s goal is to ensure that health care reform is passed and does not restrict women’s ability to purchase private health insurance that provides comprehensive reproductive health care, including abortion. The coalition announced today that it will hold a DC Lobby Day on Wednesday, December 2, as part of its National Week of Action, Monday November 30–Sunday, December 6, to ensure that the anti-choice Stupak amendment is not included in the final health care reform legislation.

The Stupak amendment, passed by the U.S. House of Representatives on November 7, would, if enacted, effectively prohibit millions of women from using their own money to purchase private health insurance that provides comprehensive reproductive health care benefits. The result would be nothing less than an unacceptable ban on abortion coverage. If this bill is enacted, millions of American women will effectively be prohibited from purchasing private insurance that covers abortion through the new “exchange” or marketplace to be established under health care reform. The Stupak amendment is a radical proposal that upends current law on abortion coverage in the United States. It goes far beyond the
Hyde amendment, which has unfairly prohibited the use of federal funds for abortion in most cases for more than 30 years. The Stupak amendment goes beyond Hyde because it would restrict abortion coverage by private health insurance plans in an unprecedented and dangerous manner.

The National Week of Action and the DC Lobby Day on December 2 will mobilize advocates from all over the country to communicate clearly to members of Congress that women need health reform that covers all of their health needs, including comprehensive reproductive health care. The coalition is building on the wave of pro-choice activism sparked by the passage of the amendment more than two weeks ago. Since passage, some members of the House who voted for the Stupak ban have expressed their doubts about this amendment. Notably, U.S. Senate Majority Leader Harry Reid did not include the Stupak language in the health care reform bill he introduced on November 19, and President Obama has indicated that the amendment goes too far.

The members of the coalition are:

Alliance for Justice
American Association of University Women
American Medical Student Association (AMSA)
Association of
Reproductive Health Professionals (ARHP)
Black Women for Reproductive Justice (BWRJ)
Black Women’s Health Imperative
Catholics for Choice
Center for Community Change
Center for Health and Gender Equity (CHANGE)
Center for Reproductive Rights
Choice USA
Coalition of Labor Union Women

EMILY’s List
Feminist Majority Foundation
Latina Sexual and Reproductive Justice Coalition (LSRJC)
MoveOn.org Political Action
NARAL Pro-Choice America
NARAL Pro-Choice New York
National Abortion Federation (NAF)
National Asian Pacific American Women's Forum (NAPAWF)
National Association of Social Workers (NASW)
National Council of Jewish Women (NCJW)
National Family Planning &
Reproductive Health Association (NFPRHA)
National Gay and Lesbian Task Force Action Fund
National Institute for Reproductive Health
National Latina Institute for Reproductive Health (NLIRH)
National Network of
Abortion Funds (NNAF)
National Organization for Women (NOW)
National Partnership for Women and Families
National Women’s Health Network (NWHN)
National Women’s Law Center (NWLC)
New Prospect Family and Worship Center, Washington, DC
No Limits
People for the
American Way (PFAW)
Personal PAC
Physicians for Reproductive Choice and Health (PRCH)
Planned Parenthood <http://www.plannedparenthoodaction.org/>
Raising Women's Voices (RWJ)
Religious Coalition for Reproductive Choice (RCRC)
Religious Institute
Sexuality Information and Education Council of the United States (SIECUS)
SisterSong Women of Color Reproductive Health Collective
Unitarian Universalist Association of Congregations

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Health Care and the Elderly.

Another segment on health care and the elderly, reposted at Religion & Ethics NewsWeekly from NPR:

SEVERSON: If Medicare costs are any measure, Miami-Dade County should have the best senior care in the country. The federal health program spends over $16,000 a year per patient. That’s about double the 2006 national average. Brian Keeley is the CEO of Baptist Health South Florida, the largest nonprofit health care system in that part of the state. He says huge Medicare costs do not translate to better health care.

BRIAN KEELEY (CEO, Baptist Health South Florida): We know that more can be injurious to people, and more health care services, more aggressively providing those services, can result in lower levels of care.

SEVERSON: He says there are several factors that bloat health care costs in the Miami area.

KEELEY: There’s a huge imbalance between the number of specialists and primary care physicians, and we have such a high percentage of specialists down over here, they utilize resources more, technology more.

SEVERSON: Dr. Strom, a specialist himself, says one reason there is such a shortage of primary care physicians is that Medicare doesn’t reimburse them enough for patient visits.

DR. STROM: If you spend a lot of time with a patient you will starve to death as a physician because you will only get paid for a certain amount of time. In fact, a lot of physicians will actually steer patients to their offices to have tests performed, because they collect both the professional component, and if they own the equipment, the technical component.

SEVERSON: Dr. Gloria Weinberg is a geriatrician and chair of the department of medicine at Mount Sinai Hospital in Miami Beach. She says when young doctors, fresh out of medical school and burdened with school loans, discover how much less a primary physician earns, they choose a specialty where they can make more money.

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300,000 Terri Schiavos.

From David Dayen at FireDogLake on the new ANH directive from the USCCB:

The US Conference of Catholic Bishops released an “Ethical and Religious Directive” this month that would ban any Catholic hospital, nursing home or hospice program from removing feeding tubes or ending palliative procedures of any kind, even when the individual has an advance directive to guide their end-of-life care. The Bishops’ directive even notes that patient suffering is redemptive and brings the individual closer to Christ.

The Catholic bishops have become more involved in political fights in recent years, particularly the issue of abortion coverage and immigration provisions in the current health care debate. This has caused a schism in the American Catholic community, which bubbled to a head yesterday with Rep. Patrick Kennedy (D-RI) being denied communion because of his position on choice.

More quietly, however, the Church has staked out a radical position on end-of-life care, without patients of the 565 Catholic hospitals and other Catholic care facilities even knowing about it. As Barbara Coombs Lee, president of Compassion and Choices, an advocacy group, put it, “When a patient goes to one of these facilities, they don’t know that they’re choosing Catholic dogma. The bishops see the hospitals as an extension of their ministry.”

The “Ethical and Religious Directives for Catholic Health Care Services” put out by the Catholic bishops would build upon a Papal allocution given in the wake of the controversial Terri Schiavo case, where the US Congress stepped in to keep Schiavo alive despite her persistent vegetative state and the wishes of her husband to end care. The papal elocution did state that the permanently unconscious should always have access to a feeding tube, but it did not have the force of doctrinal law behind it. “There was always some wiggle room” for Catholic care facilities, said Coombs Lee. Catholics were allowed to use something called a “benefit/burden balance” to determine the ethical, moral and compassionate result in any individual case.

Now, that wiggle room is gone. In the new directive, the bishops state that it is unethical and immoral to withhold or withdraw a feeding tube from patients, whether in cases of permanent unconsciousness, comas, or even cases of advanced dementia when the patient is unable to feed themselves.

This substitutes the wishes of the bishops for the stated wishes of families and the patients themselves, said Coombs Lee. Even if the family can produce an advance directive or living will, Catholic hospitals and nursing homes would be expected to maintain the feeding tubes. In addition, all Catholic health care workers are required by their faith to continue palliative care, according to the document. The directive even addresses patients. “These are directives for you, from the church,” said Coombs Lee.

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Debunked: Morphine Causes Cancer.

Thanks to the exceptional folks at GeriPal for debunking the latest meme that morphine stimulates cancer growth:

Over the last week Reuters, ABC news, MSNBC, BBC News, and more than 75 other outlets reported on how two "two new studies add to growing evidence that morphine and other opiate-based painkillers may promote the growth and spread of cancer cells." What was most shocking were the headlines used to promote the stories:
All these articles (most stemming from an initial Reuters report) discussed the recent presentation by a group from the University of Chicago on the mu-opioid antagonist methylnaltrexone (otherwise known as Relistor or “that new opioid induced constipation medication”). This work, as presented at a meeting in Boston, revealed that use methylnaltrexone prevented tumor-cell proliferation and migration in cultured lung cancer cells. The group also presented work revealing that genetically altered rodents lacking the mu-opiate receptor failed to develop tumors after being injected with Lewis lung carcinoma cells, something that did occur in normal mice. This is an interesting line of research and one that gave the makers of Relistor a shot in the arm (as one website put it – “a possible new indication for Progenix's Relistor could revive its fortunes”.) I find the pathophysiology behind this incredibly interesting from an academic standpoint, however it is neither something that would warrant such dramatic headlines nor spur thoughts that it is anything but research in its infancy.

What about the claim that there is “mounting clinical evidence” that morphine may accelerate cancer growth? The only real clinical studies in this regard come from a single institution in Ireland and are basically a couple retrospective cohort studies comparing regional versus
general anesthesia. The first one of these articles (Anesthesiology. 2006; 105(4):660-4) showed a beneficial relation between paravertebral block and cancer recurrence in women undergoing breast cancer surgery. The study’s authors acknowledge that “selection bias and the effects of unmeasuredconfounding variables” could not be excluded, as well as the fact that “relevant information such as the amount of morphine given” was not available in the records. The second study was nearly identical except it was in patients undergoing radical prostate surgery (Anesthesiology. 2008;109(2):180-7)

The most important take home point is that none of these studies actually looked at opioid use (although many of the news articles vaguely cite these studies as evidence for morphine’s deleterious effects on cancer). Even if you want to argue that these were high quality studies and there is a clear benefit of regional anesthesia, opioids should not be singled out as the cause. Benefit of regional anesthesia may be due to a myriad of other effects of regional anesthesia including the lack of volatile anesthetic agents or an improved stress response. These studies are noteworthy, but I agree with the authors of these articles that they should “be viewed as generating a hypothesis and an estimated
effect size for future large randomized controlled trials”.

So if you have a patient on morphine asking you whether “morphine will make my cancer worse”, the answer is no. There is no clinical evidence that morphine, or any other opioids, cause real harm through stimulating cancer growth. There is though significant high quality evidence for their benefit in relieving
pain and suffering.

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Chris Matthews as Uncivil as Irish Catholics.

Last night Chris Matthews had Providence, RI Tomas Tobin on his show Hardball to discuss abortion and the bishop's call for US Congressman Kennedy to forego communion. It was a heated segment. You can view it here.

Now the Catholic League is condemning Matthews for being "uncivil" to the bishop, just as those Irish Catholics tend to be....

Newsblog reports on the dust up:

Catholic League President Bill Donohue said their New York office was deluged with calls, e-mails and faxes from outraged viewers after Matthews unleashed a "tirade'' on the bishop "with an extended and quite insulting lecture."

"He had absolutely no interest in a discussion on the question of the morality and legality of abortion -- all he wanted to do was to make the bishop sit there and listen to his rant,'' Donohue said.

Bishop Tobin was a guest on the show discussing his well-publicized disagreement with U.S. Rep. Patrick J. Kennedy over health care, abortion and the congressman's standing in the church.

Donohue said, "No non-Catholic would ever treat a bishop this way. But too many liberal Catholics, especially Irish Catholics, think they are exempt from the same standards of civility that apply to others.''

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Catholic Pressure on Politicians Works.

As Joseph Bottum at First Things reminds us:

Who Says It Doesn’t Work?
Tuesday, November 24, 2009, 7:00 AM
Joseph Bottum

Apropos of the clash between Rep. Kennedy and his bishop, it’s worth remembering, as a friend emails to note, that sometimes calling politicians on abortion really does work. New Yorkers may remember this sequence from the 1980s:

• September 9, 1986: A Parish Bans Assemblyman From Speaking

• October 4, 1986: Cardinal and Assemblyman Meet on Ban

• April 11, 1989: Assemblyman Changes View On Abortions


The Truth About Houben, Locked In for 23 Years.

It is a real-life horror story. Trapped in your body for 23 years, fully conscious yet unable to communicate with those around you. The state is called "locked in" and the prospect of it happening to any one of us is alarming. We all fear the helplessness that such a trauma could bring.

As expected, the recent "awakening" of Rom Houben, a Belgian man thought to be in a persistent vegetative state since a car crash in 1983 and newly discovered as "locked in" is causing "pro-life" groups around the world to rally for suspension of assisted suicide laws.

I think the story is horrifying, yet I find it's emergence right now to be somewhat dubious. And the facts regarding Houben's initial diagnosis, 23 years if "imprisonment," and recent ability to communicate all remain unclear.

According to some reports, the Glasgow Coma Scale was used to make Houben's initial diagnosis. Yet EEG testing, a more conclusive yet still contested method of monitoring brain activity, has been in existence since the early '80s. Houben's "consciousness" was discovered in 2006 during a study at the University of Liege by Dr. Laureys who reported his findings in 2006.

Most stories about Houben tend to focus on the dramatic human element of the story. Houben's mother reportedly believed that her son understood every word she said ("I never gave up hope"), and contacted a specialist 3 years ago to request extensive testing on her son.

Stories about Mr. Houben's case are also focusing on the dilemma advocates for aid in dying and removal from artificial means of life support must face in the light of his "discovery."

Little is reported of the science behind the diagnosis, however. And still less is asked about the method Houben and his caregivers use to facilitate his communication. On a segment on MSNBC by Dr. Nancy Mr. Houlan is shown "communicating" via a computer keyboard, using what is called facilitated communication. As one writer, James Randi, a doctor familiar with facilitated communication, noted yesterday at randi.org:

I personally investigated this matter. In March of 1992 I was contacted by Dr. Anne M. Donnellan, of the University of Wisconsin-Madison, who asked if I would be willing to participate in an investigation of FC as used with autistic children. I was already familiar with FC, and suggested to her that I felt the researchers were perhaps under the influence of the Clever Hans Effect [CHE], also known as the "ideomotor effect," in which the trainer - the facilitator in this case - was unconsciously transmitting the information to the autistic child. This possibility was emphatically denied by Dr. Donnellan, and I was assured that every care had been taken to ensure that the CHE was not in operation. The Clever Hans Effect is notorious in psychology. Early in the last century, a horse named Clever Hans - in German, der Kluge Hans - was claimed to have been able to perform arithmetic and other simple intellectual tasks. In 1907, psychologist Oskar Pfungst showedconclusively that the horse was not actually performing these mental tasks, but was reacting to cues provided by his trainer.

My tests of autistic children at the University of Wisconsin-Madison clearly showed that FC was simply a tragic farce. My findings were totally ignored. The full account of this matter will be discussed in detail in my next book, A Magician in the Laboratory.

The "facilitated communication" process consists of the "facilitator" actually holding the hand of the subject over the keyboard, moving the hand to the key, then drawing the hand back from the keyboard! This very intimate participatory action lends itself very easily to transferring the intended information to the computer screen. In the video you have just viewed, it is very evident that (a) the "facilitator" is lookingdirectly at the keyboard and the screen, and (b) is moving the subject's hand. The video editing is also biased, giving angles that line up the head of the subject with the screen, as if the subject were watching the screen.

This man in the msnbc.com piece is not seeing the screen. He is not aware of what is going on. He is an unknowing victim of these charlatans. A simple test - such as that done on October 19th, 1993, in a Frontline (PBS) documentary highlighting these concerns,"Prisoners of Silence," would prove that FC is a total fraud. This powerful and comprehensive program proved that FC was a delusion.

Dr. Snyderman, how did this get by you? The evidence is right there on the screen! Others have solved this fraud. The Association for Behavior Analysis International (ABAI), the American Academy of Child and Adolescent Psychiatry, and the American Association on Mental Retardation, have no doubts about this. ABAI calls FC a "discredited technique" and warns that "its use is unwarranted and unethical." The Association for Science in Autism Treatment reviewed the research and position statements and concluded that the messages typed were controlled by the facilitator, not by the individual with autism, and that FC did not improve language skills.

We critics of FC question why people can apparently give speeches in public - via a keyboard and a "facilitator" - and go to college - similarly "assisted" - yet they cannot answer a series of simple questions under controlled conditions! Psychologist Daniel Wegner, professor of psychology at Harvard University and a fellow of the American Association for the Advancement of Science has stated that facilitated communication is a striking example of the ideomotor effect, and tests of FC show that it is a complete fraud, farce, and delusion!

I don't find Mr. Randi's diagnosis via video any more convincing than Dr. Frist's similar diagnosis of Terri Schiavo via video in 2005. But his point about Houben's manner of communicating raises questions.

As expected, Houben's story is widely being used by "pro-life" groups in the US to condemn the removal of Terri Schiavo from artificial nutrition and hydration (ANH), just at a time when the USCCB has changed their policy regarding removal of ANH, saying that this type of feeding is "obligatory" and will not be removed from patients in Catholic hospitals, regardless of the patient's or family's wishes.

A number of other factors seem to be at work in the story as well, one of which is the contested nature of assisted suicide in Belgium, which established, with regulations, the legality of assisted suicide in 2002. After Switzerland, it was the second country to do so. Groups there are still working vigorously to prevent it.

In response to the increased number of assisted suicide laws throughout the world, the Catholic church and evangelicals have stepped up their efforts to elevate "euthanasia" as a primary cause of concern. We can expect to hear Houben's name in the discourse for some time to come. I'm already seeing over-sentimentalized articles that are amplifying the "cries of the helpless," and "imagine the silent screams of the euthanized!"

This story resonates with us because it plays on our must fundamental fears of vulnerability and physical disability and plays with our innate avoidance of end of life issues. It should not, however, be confused with Death with Dignity, which honors the request of the patient, nor should it be extrapolated as representative of all the persistent vegetative patients in the country.

For more information on Behavior Analysis, see here

Read more stories about Houben here, here, here.

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