Saturday, April 10, 2010

Bioethics Panel Appointees.

Also from Michael Cook at BioEdge, a bit on the new appointees to the Presidential Commission for the Study of Bioethical Issues:

US President Barack Obama has appointed 10 more bioethics advisors, bringing membership of the Presidential Commission for the Study of Bioethical Issues up to 12. The appointees join the current chair, Amy Gutman, and vice-chair, James Wagner.

They are a diverse group. Lonnie Ali is the wife of Muhammed Ali; Anita L. Allen is a law professor at the University of Pennsylvania; Barbara Atkinson, a pathologist, is executive dean of the University of Kansas School of Medicine; Nita A. Farahany, of Vanderbilt University, is an expert in the legal and ethical consequences of neuroscience; Alexander Garza is the Assistant Secretary for Health Affairs and Chief Medical Officer for the Department of Homeland Security; Christine Grady is head of the Department of Bioethics at the National Institutes of Health Clinical Center; Stephen L. Hauser is a neuro-immunologist at the University of California San Francisco; Raju Kucherlapati is a professor of genetics at Harvard; Nelson Michael is the head of the US Military HIV Research program; Daniel Sulmasy is a Franciscan priest who works at the MacLean Center for Clinical Medical Ethics at the University of Chicago.

News of the appointments was not an item which attracted much attention in the media. However Summer Johnson, of the American Journal of Bioethics, was disappointed by a distinguished, but unimaginative, selection:

“…if nothing revolutionary happens in the world of scientific research over the next 3 years, then this commission will do fine. But history tells us this is unlikely to be the case. Moreover, this list of members really lacks creativity in terms of what a bioethics commission COULD have done. What about a systems biologist or nanomedicine researcher (in any one of the many disciplines of nanomedicine)?”

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A Lovable Old Curmudgeon.

Michael Cook at BioEdge (where you can view the trailer) writes about the upcoming HBO special on Jack Kevorkian, "You Don't Know Jack" (to air on April 24):

To be honest, along with squaring the circle and moving the immovable object I thought that making Jack Kevorkian, the American doctor who helped to mercy-kill well over a hundred people, a lovable old curmudgeon was a metaphysical impossibility. Well, blow me down, Al Pacino and Susan Sarandon have proved me dead wrong. Here's the trailer for a HBO film about a martyr for euthanasia.

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Tired and Teary.

I often think that it's the personal stories of how we make it through the dying process that are the best instruction available. At Rickety Contrivances of Doing Good, Susan Pawlick describes getting through the last days with her mother. Warm wishes, Susan.

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Real Life on the TV.

Marc Siegal at the LA Times gives us a recap of an episode of the TV show "Grey's Anatomy" on assisted suicide that takes place in Washington state, where Death with Dignity (the name of the bill/law) is legal, and tells us how accurate it is:

"Grey's Anatomy"

ABC, Thursday, March 25, 9 p.m.

Episode" "Suicide is Painless"

The premise: At Seattle Grace Hospital, patient Kim Allen ( Sara Gilbert) is suffering from stage IV (widespread) large cell lung cancer that has spread to her lymph nodes and her liver. She has had repeated pleural effusions (fluid has built up in her lungs, which she has had drained), and she continues to have difficulty breathing. She is in constant pain and is told that she has less than six months to live.

Allen has been offered hospice care with its attempts at pain relief and heavy sedation, but she is considering physician-assisted suicide instead. A psychologist has declared her mentally fit, and she asks her doctor, Dr. Teddy Altman (Kim Raver), to help her die. She seems open to the possibility, but in Washington state, according to the show, physician-assisted suicide is legal only if two physicians agree and the request is made by the patient twice, 15 days apart.

The second doctor who is asked to evaluate her, Dr. Owen Hunt (Kevin McKidd), is reluctant to approve her request. Finally, with both Altman and Hunt in agreement, Allen is sent home with a prescription for barbiturates, which Altman tells her will stop her breathing 45 minutes after she takes them.

The medical questions: Is stage IV large cell lung cancer usually terminal in less than six months or can it still be treated successfully with chemotherapy? Can a patient with extensive lung cancer be made comfortable with the help of sedation, pain medication and hospice care — without rendering her unconscious or stopping her breathing? Is physician-assisted suicide legal in Washington state provided that two physicians agree and the patient is mentally competent? Are barbiturates usually prescribed for use outside the hospital in such a case? Could a dose be determined that would predictably stop a patient's breathing in 45 minutes?

The reality: Chemotherapy can sometimes extend the survival of stage IV large cell lung cancer patients beyond six months, but it is often ineffective. The median time to death is eight months, says Dr. Joseph Lowy, medical director of the Palliative Care Service at NYU Langone Medical Center. Only 20% to 30% of patients are alive at one year, so the show's prediction of less than six months for Allen is fairly realistic.

Sedation, pain medication and hospice care can make such a patient comfortable, but shortness of breath can be a particularly difficult symptom to treat, says Dr. Timothy E. Quill, professor of medicine and psychiatry at the Center for Ethics, Humanities, and Palliative Care at the University of Rochester School of Medicine in New York. A patient might be suffering and not be able to report it because they are heavily sedated, Quill says.

In physician-assisted suicide, a physician generally evaluates the patient and then prescribes potentially lethal medication that the patient then takes (or not) by his or her own hand. It has been legal in Washington state since March 5, 2009, and yes, two physicians must agree on the prognosis (that the patient will die within six months), the competence of the patient and the voluntary nature of the request. "There must be no acceptable alternatives," Quill says.

Evaluation by a psychologist or psychiatrist is not required, says Dr. Shawn J. Skerrett, professor of pulmonary medicine at the University of Washington, adding that he's uncomfortable participating in physician-assisted suicide, in part because of "the lack of a requirement to exclude depression by a mental health professional."

Barbiturates are the most common medication prescribed for this use. Data from Oregon indicate that the drugs are consistently effective, but some research suggests that assessing the proper dose can be problematic. In 2009, for example, 36 patients took lethal doses of prescribed medication under the Washington state Death With Dignity Act. In six cases, death took more than 90 minutes.

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