HealthLawProf Blog

Justice O'Connor and the Uninsured

The Mahablog posts a recent speech highlighted in the Boston Globe by Justice O'Connor discussing the plight of the uninsured.  Boston Globe reporter Laurence J. Kotlikoff, reports,

Big numbers, like 45 million uninsured Americans, are hard to grasp. But that number came home to me at a recent conference. The keynote speaker was former Supreme Court justice Sandra Day O'Connor. Her topic was our healthcare system, and her message was personal and anguished.

The gist was that even she lives in constant fear of major uninsured health bills. Not her own -- those of her son. He can't afford insurance because his son -- her grandchild -- has a preexisting condition.

As I listened, a light dawned: O'Connor and the rest of us with health coverage are also uninsured. We too face terrible, albeit more remote, healthcare risks -- the risk that our employer will drop our plan, that Medicare will go bust, that our plan won't cover our needs, that premiums will eat us alive, that our doctor will stop taking our insurance, that long-term care will wipe us out, and that our uninsured friends and family members will need major financial help.

These risks are entirely avoidable. We can have an efficient, transparent system that includes everyone; treats everyone fairly; covers all the basics, including prescription drugs, home healthcare, and nursing home care; and costs little more than what we now spend. But we can't get there via the piecemeal reforms that President Bush, most of his would-be successors, and our state governors are advocating. . . . .

I don't agree with his proposed solution but it is different that what I have heard before -

My solution is called the Medical Security System. It would eliminate Medicare, Medicaid, and (by dropping the tax breaks) employer-based healthcare. The government would give everyone a voucher each year for a basic health plan. The size of the voucher would be based on one's health status. Those in worse health would get bigger vouchers, leaving insurers no incentive to cherry-pick. Furthermore, insurers would not be permitted to refuse a voucher or otherwise deny coverage.

The government would set the total voucher budget as a fixed share of gross domestic product and determine what a basic plan must cover. We would choose our own health plans. If we cost the insurer more than the voucher, he would lose money. If we cost him less, he would make money. Insurers would compete for our business and could tailor provisions, like co-pays and incentives to stop smoking, to limit excessive use of the healthcare system and encourage healthy behavior.

Nothing would be nationalized. Virtually all of the cost would be covered by redirecting existing government healthcare expenditures as well as tax breaks. Doctors, hospitals, and insurers would continue to market their services on a competitive basis.

This is not a French, British, or Canadian solution. It's an American, market-based solution that Republicans should love. It's also a progressive solution that Democrats should love. (Democratic presidential candidate Mike Gravel has endorsed it.) The poor, who are, on average, in worse health, will receive, on average, larger vouchers. The rich will lose their tax breaks.

Why can't a country as rich as ours come up with a system that works? This, in essence, was Justice O'Connor's parting question.

But, in fact, we can. Now if we can just get the big cheeses in the Oval Office or on their way there to start thinking big . . .

Mahablog has further commentary on the need for reform. 

World Health Organization and Spread of Infectious Disease

The New York Times writes about on the WHO's report concerning the spread of infectious diseases in our increasingly mobile world.  The report informs us that more communication and sharing of data is essential: 

New infectious diseases are emerging at an “unprecedented rate,” and far greater human mobility — by planes, trains and ships — means that diseases have the potential to spread rapidly across the globe, a World Health Organization report warned this week.

      

Because of this risk, greater international cooperation among governments and scientists is essential, said Dr. Margaret F. C. Chan, director general of the health organization.  “Given today’s universal vulnerability to these threats, better security calls for global solidarity,” Dr. Chan said in a statement that accompanied the World Health Report 2007, issued in Geneva, where the organization is based. “The new watchwords are diplomacy, cooperation, transparency and preparedness.”

Much of the report focuses on how health officials should respond to a more globalized world.  In 2003 the outbreak of SARS, or severe acute respiratory syndrome, was spread from mainland China to Hong Kong and then on to Singapore and Canada via airline passengers. Another factor is that many migrants now travel around the world for work. A polio epidemic that started in Nigeria most likely moved to countries including Yemen on ships carrying migrant workers, organization officials say.

Dr. Chan, who was Hong Kong’s top health official during the SARS outbreak there, has been in her new office less than a year, and the health organization’s experiences during her tenure have underlined the need for improved international cooperation and communication.

I didn't realize that profit was concern in these situations --

For much of the year, the World Health Organization was haggling with China and Indonesia over their unwillingness to share samples of the avian influenza, or bird flu, virus. Both countries have serious problems with the disease, and such samples help international scientists at the health organization track the spread and evolution of the virus, to better predict the likelihood of a global pandemic.  But the samples can also be used for vaccine development, and some countries express fears that the profits and credit for a vaccine would be lost if samples were sent to Geneva. . . . .

Breast Cancer Rates and Hormone Therapy

Reuters reports on recent data published in the 5th Journal of the National Cancer Institute showing a decline in breast cancer rates which appears related to a decline in the use of hormone replacement therapy.

"It's encouraging that breast cancer rates decreased with decreases in use of hormone therapy," Dr. Karla Kerlikowske told Reuters. This implies that women who stopped using hormone therapy in a relatively short period of time have a risk of breast cancer similar to women who have never used hormone therapy."

Kerlikowske from San Francisco Veterans Affairs Medical Center and the University of California, San Francisco, and colleagues examined whether parallel declines in postmenopausal HRT use and rates of breast cancer are present among women undergoing routine screening mammography.

They point out that the breast cancer detection rate is higher in women undergoing mammography, so "the proportion of women in the population undergoing routine screening mammography will influence population-based estimates of breast cancer incidence."

The prevalence of postmenopausal HRT use started to decline about the same time that observational studies in early 2000 linked use of estrogen and progestin combinations to greater breast cancer risk than use of estrogen alone. An even greater decline followed the release of the Women's Health Initiative study in 2002.

The current study involved over 600,000 screening mammograms on women 50-69 years of age, of whom 3238 had breast cancer. The rate of estrogen receptor-positive invasive cancer was stable until 2001, but declined 13 percent per year from 2001 to 2003, the report indicates. Rates of estrogen receptor-negative invasive cancer did not change during this interval. . . . .

Conference Announcement:

Setting an ethical agenda for health promotion

An interdisciplinary conference on the ethics of health promotion and public health

18 – 20 September 2007, Ghent   University, BELGIUM

REGISTRATION CLOSES 7^th SEPTEMBER!

Keynote Speakers:

 

Norman DANIELS (Harvard University)

Angus DAWSON (Keele University)

Ronald BAYER (Columbia University)

Nancy KASS (Johns Hopkins University)

Luk JOOSSENS (ECL)

Marcel VERWEIJ (Utrecht University)

Maurice MITTELMARK (University of Bergen)

Lea MAES (Ghent University)

Ted SCHRECKER (University of Ottawa)

Andrew TANNAHILL (Health Scotland)

 

Details, full programme and registration forms available from the conference website at: http://www.healthpromotionethics.eu

 

US Cancer Survival Rate

The Lancet (free registration) released data showing that the United States having the best survival rate for cancer.  This is great news!  Ezra Klein analyzes further what this information really means.  He writes,

Andrew Sullivan is quite pleased that the US is #1 in cancer survival rates.  So am I!  Problem is, we don't know what that means. The US has the most aggressive tumor screening in the world. That means we find some tumors earlier, but we also find many tumors that would have been non-lethal, or proven so slow-growing that something else would have killed the individual before the cancer did. In those cases, our treatments are, at best, an enormous waste of money, and at worst, more damaging than the disease. The question is how many otherwise lethal cancers we're curing, not merely how many cancers we're curing (or slowing).

Moreover, simply having the highest survival rates isn't a particularly useful metric of whether we're getting good value for our money. Our 5-year cancer survival rate, according to the study Andrew links, is 62.9%. Italy's is 59%. Italy spends about $2,532 per person. America spends about $6,100. And these numbers, incidentally, are adjusted for purchasing power parity. Then there's the question of who our treatment is best for.  Not the poor.  Studies show significantly lower mortality rates for the low-income cancer patients in Canada than in the US. Is this all a good deal? Maybe. But Sullivan should explain why we should believe that. . . .

For a different take, see the Ayn Rand Institute.

Moral Hazard and Health Care

For a quick de-bunking of the health insurance as a moral hazard, Lawyers, Guns and Money (what a combo), has a good post,

Repeating a frequent argument, a commenter to this thread says:

Frankly, this gets us to one legitimate critique libertarians have of universal health care: it can be used to bootstrap lots more nanny statism. I can live with that given the net positives of having a better health care system, but it's regrettable.

For this reason, however, it's worth noting that the argument is lousy, a subset of the utterly bizarre belief that medical care works according to similar incentives as markets for consumer goods. As Malcolm Gladwell notes with respect to the claim that having health insurance (rather than paying for doctors out of pocket) represents a major moral hazard:

The moral-hazard argument makes sense, however, only if we consume health care in the same way that we consume other consumer goods, and to economists like Nyman this assumption is plainly absurd. We go to the doctor grudgingly, only because we’re sick. “Moral hazard is overblown,” the Princeton economist Uwe Reinhardt says. “You always hear that the demand for health care is unlimited. This is just not true. People who are very well insured, who are very rich, do you see them check into the hospital because it’s free? Do people really like to go to the doctor? Do they check into the hospital instead of playing golf?” . . . . .

None of this surprises me, because the argument also strikes me as illogical on its face. The thing is, being healthy is its own powerful incentive. Maybe I'm unusual, but even though I have decent health insurance I don't actually enjoy being sick, bedridden, in physical pain, spending time in doctor's offices, etc. Do people really think it's common -- even subconsciously -- for someone with a relatively healthy lifestyle to get health insurance and see that as an opportunity to go on that all Popeye's, deep-fried HoHos, and Cutty Sark diet they've been hankering for? I don't understand this reasoning at all. There may be room for some minor disincentives at the margin, but the idea that universal healthcare won't work because the possibility of being bankrupted by medical bills is the major incentive people have to be healthy is bizarre.

The structure of a universal care system should somehow promote and reward healthy living.

How does one deter the freeloaders who take poor care of themselves and then overuse the system for years on end (as sort of mental health therapy)? "It will not happen" is a questionable response - it happens now.

Flu Season: Are we ready?

Just in time, The Next Hurrah has blogged about the Australian flu season and provides some insight into whether the United States is prepared for the flu season. . . .  The site states,

Severe flu seasons can be as bad or worse than a mild pandemic. Here's a post from our colleague Revere, one of the epidemiologists at Effect Measure, the pogressive public health blog, outlining exactly that. From Effect Measure:

Given our posts (here, here) on the particularly severe flu season in Australia, we thought it useful to remind ourselves that a bad flu season can be really bad -- worse than the 1918 pandemic in some locations. Here is a post we did back in April 2006 about an interesting paper (see link in post) by Cecile Viboud and her colleagues at NIH that looks at historical records on flu mortality. Flu is a bad disease, pandemic strain or not. Why some flu is worse than others we don't know.

The hospital diversions and capacity overflow is a reminder that health issues in this country (not just Australia) need to be kept front and center as a priority. A bad flu season would overwhelm our own EDs

A [2002] study to be published in the April 2002 Annals of Emergency Medicine on emergency department use and capacity in California, sheds light on the overcrowding problem nationwide and provides the first objective data on this crisis in the United States. (Trends in the Use and Capacity of California's Emergency Departments, 1990-1999).

The study finds that in the past decade (1990-1999) emergency departments in California decreased by 12 percent, while the number of emergency department visits at each hospital increased 27 percent to about 25,778 annually.

and the efforts to prepare for a flu pandemic (whatever strain of virus) only highlight the health infrastructure issues here in the US that are every bit as ignored as crumbling bridges... until they collapse. To their credit, California is trying to address surge capacity issues in their hospitals. Is that happening in other states, with backing from the legislatures?

The SCHIP program's proposed expansion to cover underinsured children (and Bush's virulent and mean-spirited opposition) is in the news now, and other health care issues need to stay in the news through the primaries and right up to the election. Government has an important role in rebuilding our health infrastructure, and we need to make sure the candidates from both parties articulate what they see that role as. . . . .  (See Gene Sperling's evaluation of SCHIP).

New Standards for SCHIP

I am not sure why the President decided to issue these new standards for State Children’s Health Insurance Program (SCHIP) late, last Friday (oh, wait - they look like they might be incredibly unpopular so perhaps he hoped no one would notice . . . ).   The New York Times reports on the President's battle to prevent expanding the coverage of SCHIP:

The Bush administration, continuing its fight to stop states from expanding the popular Children’s Health Insurance Program, has adopted new standards that would make it much more difficult for New York, California and others to extend coverage to children in middle-income families.  Administration officials outlined the new standards in a letter sent to state health officials on Friday evening, in the middle of a month-long Congressional recess. In interviews, they said the changes were aimed at returning the Children’s Health Insurance Program to its original focus on low-income children and to make sure the program did not become a substitute for private health coverage.  After learning of the new policy, some state officials said today that it could cripple their efforts to cover more children by imposing standards that could not be met.  . . .

The poverty level for a family of four is $20,650 in annual income. New York now covers children in families with income up to 250 percent of the poverty level. The State Legislature has passed a bill that would raise the limit to 400 percent of the poverty level — $82,600 for a family of four — but the change is subject to federal approval.  . . . .

In the letter sent to state health officials about 7:30 p.m. on Friday, Dennis G. Smith, the director of the federal Center for Medicaid and State Operations, set a high standard for states that want to raise eligibility for the child health program above 250 percent of the poverty level.  Before making such a change, Mr. Smith said, states must demonstrate that they have “enrolled at least 95 percent of children in the state below 200 percent of the federal poverty level” who are eligible for either Medicaid or the child health program.

Deborah S. Bachrach, a deputy commissioner in the New York State Health Department, said, “No state in the nation has a participation rate of 95 percent.”  And Cindy Mann, a research professor at the Health Policy Institute of Georgetown University, said, “No state would ever achieve that level of participation under the president’s budget proposals.”  The Congressional Budget Office has said that the president’s budget, which seeks $30 billion from 2008 to 2012, is not enough to pay for current levels of enrollment, much less to cover children who are eligible but not enrolled.

When Congress created the Children’s Health Insurance Program in 1997, it said the purpose was to cover “uninsured low-income children.” Under the law, states are supposed to make sure public coverage “does not substitute for coverage under group health plans;” but the law did not specify what states must do.  In an interview today, Mr. Smith said: “The program was always meant for children in lower-income families. As states move higher up the income scale, it’s more likely to substitute for private coverage.”

The Next Hurrah and Firedoglake have some excellent comments on the President's new standards.

Manufacturing and/or Defining Life

The Associated Press reports on the latest struggle for scientists: defining life.  The story states,

In suburban Washington this summer, prominent scientists at the J. Craig Venter Institute, who were key players in mapping the human genome, switched DNA from one bacterium into another, changing its genetic identity. That put the world on notice that man's ability to manipulate life is dancing around the point of creation.

Now Venter is asking for a patent for a completely new bacteria that would be created by inserting genes into a hollowed-out cell of what once was a urinary tract bug. Venter doesn't view that as creating life, just "modifying life to come up with new life forms."
At least half a dozen other research teams around the world are going farther, trying to create life out of chemicals, mimicking the beginnings of life on Earth. They're somewhere from three to 10 years from success, they figure.

For them, and Venter, new man-made life forms mean new energy sources, environmental clean-up mechanisms and life-saving medicines. For others, such a breakthrough would mean understanding how life began on Earth by trying to recreate it. . . .

Many scientists familiar with these challenges of defining life say the answers won't be easy to find. "It's an important but ultimately frustrating question if one expects to come up with a nice clean shiny answer; it ain't going to happen," said Francis Collins, a prominent Christian scientist and director of the National Human Genome Research Institute.

That talk about life is going to get uncomfortable as dreams of creation, from Frankenstein's monster on, get closer to reality, said University of Pennsylvania bioethicist Art Caplan. "This issue of 'what is life' has been at the core of biology for about 400 years," Caplan said. He said it leads to the more theological questions about whether life is special and whether we are special. Later this century, the definition of life will be at the heart of a political and societal debate as heated and divisive as abortion and embryonic stem cell research, Caplan predicts.

Look for changes in religion, too.

"As knowledge has (been) added, religions have adapted," Venter said. "I don't see why this is any different. We're pushing the frontiers of knowledge, understanding life on this planet."
Venter dismisses suggestions that scientists are playing God as media sensationalism. And Collins, a scientist who talks at length about his faith, said he finds it interesting that the people who most often use the phrase "playing God" usually don't believe in God.

"Playing God" is a secular, not religious, term, said Ted Peters, a professor at the Graduate Theological Union in Berkeley, Calif., and author of the book "Playing God." He said people who worry about that are really talking about tinkering with nature. "What Craig Venter is doing is an extremely complicated form of animal breeding," Peters said. "We're going to be changing the face of the planet no matter what. The question is do we want to do it responsibly or not?"

C. Ben Mitchell, a bioethicist connected with Trinity University, an evangelical Christian college in Illinois, worries about entrusting such monumental developments with scientists.
"Human history is enough; it is sufficient to remind us of the problem of hubris," Mitchell said. "It is at least a cautionary note, to caution us to be aware of unintended consequences.". . . .

Use of Pain Medicine Medication in US Increases Dramatically

Oops!  The headlines on this Associated Press article are a bit misleading when one reads the article and discovers the reasons for the increase in use of pain medication (it is not because people are deeply depressed over the stock market woes, the entire Bush Presidency, or the latest Britney Spears rehab debacle).  The Associated Press reports,

Retail sales of five leading painkillers nearly doubled over the last eight years, reflecting a surge in use by patients nationwide who are living in a world of pain, according to a new Associated Press analysis of federal drug prescription data. The analysis reveals that oxycodone usage is migrating out of Appalachia to areas such as Columbus, Ohio, and Fort Lauderdale, Fla., and significant numbers of codeine users are living in many suburban neighborhoods around the country.  The amount of five major painkillers sold at retail establishments rose 90 percent between 1997 and 2005, according to Drug Enforcement Administration figures.  More than 200,000 pounds of codeine, morphine, oxycodone, hydrocodone and meperidine were purchased at retail stores during 2005, the most recent year represented in the data. That is enough to give more than 300 milligrams of painkillers to every person in the country. . . .

Dr. Jeffrey Gordon, director of the blood and cancer center at Day Kimball Hospital in Putnam, Conn., said Vicodin is a popular painkiller to give patients after surgery, and many doctors are familiar with it. "Over the past 10 years, there has been much better education in the medical community to ... ask if people are having pain and to better diagnose and treat it," Gordon said.

An AP investigation found these reasons for the increase:

_The population is getting older. As age increases, so does the need for pain medications. In 2000, there were 35 million people older than 65. By 2020, the Census Bureau estimates the number of elderly in the U.S. will reach 54 million.

_Drugmakers have embarked on unprecedented marketing campaigns. Spending on drug marketing has zoomed from $11 billion in 1997 to nearly $30 billion in 2005, congressional investigators found. Profit margins among the leading companies routinely have been three and four times higher than in other Fortune 500 industries.

_A major change in pain management philosophy is now in its third decade. Doctors who once advised patients that pain is part of the healing process began reversing course in the early 1980s; most now see pain management as an important ingredient in overcoming illness.  Retired Staff Sgt. James Fernandez, 54, of Fredericksburg, Va., survived two helicopter crashes and Gulf War Syndrome over 20 years in the Marine Corps. He remains disabled from his service-related injuries and takes the equivalent of nine painkillers containing oxycodone every day.  "It's made a difference," he said. "I still have bad days, but it's under control." . . .

"I'm concerned and many people are concerned, that the pendulum is swinging too far back," he said.

Consider:

_More people are abusing prescription painkillers because the medications are more available. The vast majority of people with prescriptions use the drugs safely. But the number of emergency room visits from painkiller abuse has increased more than 160 percent since 1995, according to the government.

_Spooked by high-profile arrests and prosecutions by state and federal authorities, many pain-management specialists now say they offer guidance and support to patients but will not write prescriptions, even for the sickest people. The increase in painkiller retail sales continues to rise, but only barely. There was a 150 percent increase in volume in 2001. Four years later, the year-to-year increase was barely 2 percent.

_People who desperately need strong painkillers are forced to go long distances — often to a different state — to find doctors willing to prescribe high doses of medicine. Siobhan Reynolds, widow of a New Mexico patient who needed large amounts of painkillers for a connective tissue disorder, said she routinely drove her late husband to see an accommodating doctor in Oklahoma.

The article goes on to discuss some of the prosecutions that have occurred and some of the evidence of abuse.  Although it appears some may have distributed pain medication in an illegal manner, many doctors now fear prosecution for helping their patients manage their pain. 

Medicare and Preventable Errors

The New York Times reports that Medicare will no longer pay hospitals for costs deemed the result of " treating preventable errors, injuries and infections that occur in hospitals."  The Bush administration claims that this change will help save lives and lots of money.  The Times reports,

Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”  Among the conditions that will be affected are bedsores, or pressure ulcers; injuries caused by falls; and infections resulting from the prolonged use of catheters in blood vessels or the bladder.  In addition, Medicare says it will not pay for the treatment of “serious preventable events” like leaving a sponge or other object in a patient during surgery and providing a patient with incompatible blood or blood products. . . .

The new policy — one of several federal initiatives to improve care purchased by Medicare, at a cost of more than $400 billion a year — is sending ripples through the health industry. It also raises the possibility of changes in medical practice as doctors hew more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission.  Hospital executives worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat amount for each case.

The Centers for Disease Control and Prevention estimates that patients develop 1.7 million infections in hospitals each year, and it says those infections cause or contribute to the death of 99,000 people a year — about 270 a day. . . .

Consumer groups welcomed the change. And while hospital executives endorsed the goal of patient safety, they said the policy would require them to collect large amounts of data they did not now have.  Lisa A. McGiffert, a health policy analyst at Consumers Union, hailed the rules. “Hundreds of thousands of people suffer needlessly from preventable hospital infections and medical errors every year,” Ms. McGiffert said. “Medicare is using its clout to improve care and keep patients safe. It’s forcing hospitals to face this problem in a way they never have before.” . . .

Genetic Discrimination in the Army

The LA Times has a detailed article on the Army's use of genetic information - and surprise, surprise, it isn't using this information to try to to help its soldiers.  It reports,

Eric Miller's career as an Army Ranger wasn't ended by a battlefield wound, but his DNA. Lurking in his genes was a mutation that made him vulnerable to uncontrolled tumor growth. After suffering back pain during a tour in Afghanistan, he underwent three surgeries to remove tumors from his brain and spine that left him with numbness throughout the left side of his body.   So began his journey into a dreaded scenario of the genetic age. Because he was born with the mutation, the Army argued it bore no responsibility for his illness and medically discharged him in 2005 without the disability benefits or health insurance he needed to fight his disease.  "The Army didn't give me anything," said Miller, 28, a seven-year veteran who is training to join the Tennessee Highway Patrol. . . . .

"You could be in the military and be a six-pack-a-day smoker, and if you come down with emphysema, 'That's OK. We've got you covered,' " said Kathy Hudson, director of the Genetics and Public Policy Center at Johns Hopkins University."But if you happen to have a disease where there is an identified genetic contribution, you are screwed."  Representatives from the Pentagon declined multiple requests to discuss the policy.

A high cost

The regulation appears to have stemmed from an effort to protect the armed services from becoming a magnet for people who knew they would come down with costly genetic illnesses, according to Dr. Mark Nunes, who headed the Air Force Genetics Center's DNA diagnostic laboratory at Keesler Air Force Base in Mississippi.

The threat is almost certainly small. A 1999 military analysis estimated that about 250 service members are discharged each year for health problems involving a genetic component. Disability payments for them would amount to $1.7 million the first year and rise each year after that as more veterans join the rolls. Healthcare expenditures would have added to the tab.

"Maybe they didn't want to foot the bill for my disability," said Miller, whose rare genetic disease is called Von Hippel-Lindau syndrome. "It's saving money for them. I'm just one less soldier that they have to dish out compensation to."

But the cost for individuals medically discharged can be high. While some eventually receive benefits from Veterans Affairs or private insurers, the policy leaves Miller and others scrambling to find treatment for complex medical conditions at the same time they are reestablishing their lives as civilians without having the benefit of Tricare, the military's health insurance.

"It seems particularly draconian to say, 'Well, you're out with no benefits,' whereas another person with the same injury gets the coverage simply because we don't know there's a gene in there that's causing this," said Alex Capron, a professor who studies healthcare law, policy and ethics at USC.

The entire article is worth the read and provides another example of how we need to reform our health care system. 

Embryo Culture by Beth Kohl

Salon.com has an interview with Beth Kohl, the author of Embryo Culture.  The book discusses not only the new reproductive technologies but also many of the moral concerns that individuals have concerning the use of these technologies.  Here is the introduction to the interview:

After a year of trying to get pregnant in the time-tested manner (intercourse with mate, slow jams and cocktails optional), Beth Kohl discovered that, like 6.1 million of her fellow Americans, she was clinically infertile. So she and her husband, Gary, then 29 and 32 years old, respectively, embarked on a different, but increasingly common, baby-making journey -- one using assisted reproductive technology (ART) to conceive.

But along with prenatal vitamins and baby-name books, Kohl found a mess of ethical questions. Why spend so much time and money conceiving bio-kids when many already-born babies could benefit from the same resources? How many embryos is it OK to transfer, given that later a mother might be faced with the decision to selectively reduce (read: abort) one or more of her fetuses? Are IVF kids the same -- healthwise, soulwise -- as naturally conceived children? What about the risk of pregnancy complications, premature birth, and the host of long-term problems that come along with them? Can "man-made" babies ever be reconciled with religious faith? And the biggie: What should would-be parents do with their leftover embryos?

Kohl, who grew up in a conservative Jewish household in suburban Milwaukee, tackled her ethical and reproductive journey with a typically Midwestern work ethic, digging for answers in sources ranging from the Bible to congressional testimonies about forced abortion in China. Now she chronicles her struggle, both with fertility and morality, in a new book, "Embryo Culture: Making Babies in the Twenty-First Century." The bones of "Embryo Culture" is Kohl's own story of two IVF-assisted pregnancies, but she beefs it up with an impressive amount of research on the technical matters and moral questions facing would-be parents, clinicians and the government.

While the subject is serious, her touch is light. Trying to find a metaphor for their infertility, her husband suggests "botanists in the Arctic Circle" -- and Kohl replies: "That is better. Not only does it suggest that my uterus is inhospitable to life, it also manages to hint of my frigidity." She's compassionate, but unsentimental (especially when you compare "Embryo Culture's" language to the banter in infertility chat rooms and blogs. Kohl reports that some women refer to their frozen embryos as "embies" and nickname the eight-cell clusters "Frosty" and "Snow White"). And she never claims to have all the answers.

Tobacco Regulation

William Saletan has a piece in Slate.com this week discussing the "Tobacco Jihad."  Although he dislikes smoking and notes that it is an extremely unhealthy habit, he also states that perhaps other "drugs" need to be viewed more cautiously as well,

Likewise, the point of recognizing tobacco as a drug was to regulate it as strictly as comparable drugs, not more so. Five months ago, a report by a British commission found that the financial health costs of alcohol and tobacco were equal. Tobacco was by far the bigger killer, but when the analysis moved beyond self-destruction to harming others, the annual death toll from alcohol-related car accidents exceeded the toll from secondhand smoke in the workplace. Drinking, unlike smoking, played a role in 78 per cent of assaults and 88 per cent of criminal damage. The commission concluded that if legal drugs were classified like illegal ones, alcohol would be judged more serious than tobacco. Instead, British law allows advertising of booze but not cigarettes.

The strangest thing about the current round of smoking bans is its focus on pubs. All over the world, reporters have been interviewing bar patrons about the merits of expelling tobacco. "It means I can drink and not come out [of] the bar stinking like an ash-tray," one guy in Hong Kong told Agence France-Presse after a night of partying. There's nothing more annoying than a stinking cigarette when you're trying to get stinking drunk.

Tobacco myopia isn't just a British problem. In South Korea, a university president has proposed to permit booze but "remove smoking students from our school." In Amsterdam, coffee-shop patrons will soon be allowed to smoke marijuana but not tobacco, despite evidence that two joints cause as much non-cancerous lung damage as five to 12 cigarettes.

I understand that alcohol is also a danger to public health, however, I don't think that regulation of alcohol means that we should cut back on our regulation of tobacco.   I am sure that there are healthy vices - perhaps dog walking - that people could take up without the associated downsides of tobacco and alcohol.

Interesting Health Care Discussion

Kevin Drum at the Washington Monthly on-line takes a look at Phil Longman's article examining Jonathan Cohn's new book, Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price.  Both pieces are interesting and provide great discussions and critiques of our current health care system.

Girls with Autism

Bruce Godsey, a guest blogger at Majikthise, has a terrific post examining Emily Bazelon's reporting in the New York Times on girls with autism and the treatment that they receive.  He writes,

In terms of understanding autism, we in 2007 have little right to scoff at our ancestors who treated diseases with leeches, as our understanding of this surprisingly prevalent variety of neurological and development disorders awkwardly called "autism-spectrum disorders" stands at approximately the blood-letting stage. A great deal of misinformation about this "set of disorder sets" is available, some of it pushed by people with well-intentioned and/or venal agendas.  Some have heard that mercury in vaccinations has a scientific causal link to autism; it has no actual link but rather a sloppy pseudo-scientific one, i.e. pure gahhr-bazzh. While a skeptical, evidence-demanding approach to life is always of merit, it is particularly important when one is dealing with disorders about which little is known but a great deal of money and human emotion hangs in the balance.

My interest in the topic is personal, so a little of our personal background.  Both of our sons, Sam 4, Noah 2, are autistic.  Their personalities are quite different; Sam is fairly narrowly focused, quiet verbally and easily frustrated but never manic, whereas Noah is a ball of whining energy and eager beaver chatter to himself  We assume that both boys developed autistic neurology through genetics, though no one else in the family has a diagnosis.  While the adult men of my family, myself included, tend towards "nerdish" ways and are mostly introverted, we do not stand on the autistic spectrum.  Among my wife's family, ditto except perhaps for one uncle.  We do not live in a part of the country where autism is particular prevalent; the highest rates of autism in the U.S. are said to be in Silicon Valley, i.e. Santa Clara County, CA, though the extent to which sample bias, confirmation bias, better testing, a more educated pool of parents or other factors may cast doubt on that statistic's weight is unclear.

It is very likely that different genetic conditions cause the many of the same or similar symptoms of the different autism spectrum disorders.  Autism is more common among boys than among girls but not overwhelmingly so in the manner of, for example, hemophilia, adding to the likelihood that some autism results from Y chromosome recessive genes while other autistic manifestations may not.  It is also possible - indeed practically guaranteed - that our own perceptions are gender-skewed, both on what "normal" [sic] is for either gender or how different autism-spectrum disorders may play out differently (or similarly) for girls and boys.

Also, today on NPR's Morning Edition, there was a brief story about an incredibly dedicated group of women in South Carolina who successfully crafted and helped enact legislation requiring insurance companies to cover autism treatments, which are extremely expensive. 

Pharmacists and Plan B in Illinois

In Ethan Vandersand v. Wal-Mart Stores, Inc., an Illinois federal district court has refused to dismiss a suit by Illinois pharmacists that they should not be required to comply with a  2005 rule by Governor Rod Blegojevich requiring Illinois pharmacies to dispense emergency contraception/Plan even if individual pharmacists disprove of the medication for religious or moral reasons.  According to a brief write-up by  PJStar.com,

Several pharmacists employed by Wal-Mart and Walgreen Co. have been disciplined for either refusing to dispense Plan B or for refusing to promise that they would dispense emergency contraception if asked.

U.S. District Judge Jeanne Scott denied a request Tuesday by Wal-Mart to throw out a lawsuit filed by pharmacist Ethan Vandersand. Scott sided with Vandersand, who had claimed he was legally protected from discipline by the Illinois Health Care Right of Conscience Act when he declined to dispense Plan B.

Vandersand, who lives in Bluffs, formerly worked at the pharmacy in Beardstown's Wal-Mart. He was put on unpaid leave after he refused to fill a Plan B prescription requested by a nurse practitioner at Springfield's Planned Parenthood on behalf of a female patient in February 2006.  Wal-Mart had contended the state's right-of-conscience law doesn't cover pharmacists. Walgreen Co. has made the same argument in other Illinois lawsuits filed by fired pharmacists.

But Scott wrote in her ruling, "The statute prohibits discrimination against any person for refusing to provide health care because of his conscience."

Caregiver Syndrome

CNN.com reports on a newly named syndrome,

Do you take care of someone in your family with a chronic medical illness or dementia? Have you felt depression, anger or guilt? Has your health deteriorated since taking on the responsibility of caregiving? If your answer is yes to any one of these, you may be suffering from caregiver stress.

This condition is increasingly being referred to as "caregiver syndrome" by the medical community because of its numerous consistent signs and symptoms. In the pamphlet, "Caring for Persons with Dementia," Dr. Jean Posner, a neuropsychiatrist in Baltimore, Maryland, referred to caregiver syndrome as, "a debilitating condition brought on by unrelieved, constant caring for a person with a chronic illness or dementia."

An increasing number of Americans are finding themselves taking care of someone who's aging or ill or both. According to the American Academy of Geriatric Psychiatrists, one out of every four American families cares for someone over the age of 50. As America's population ages, that number is expected to skyrocket. In 2000, the Census Bureau reported, just under 35 million Americans were 65 or over; by 2030, the number is projected to more than double, to more than 71 million. . . . .

The article provides a quick overview as to why many of these caregivers fail to recognize their own need for help and understanding as they deal with these challenges.

Women Veterans Suffer More PTSD

McClatchy News reports on the women war vets from Iraq and the reasons for their higher incidence of post-traumatic stress disorder.  They discuss a recent article in the Washington Times stating,

'The problem becomes even more complex in the context of women serving in the military. In their combat roles, service women in Iraq are subject to both violence from the war and assault from fellow service members or superiors. According to a 2003 study, about one-third of female veterans visiting the Veterans Administration for health care reported having been subject to rape or attempted rape during their military service.

The combination of sexual assault with the psychological trauma from combat known to contribute to PTSD in military personnel has created an environment in which an estimated 20 percent of servicewomen will develop this condition — 4 times the rate in the civilian population and more than double the rate of PTSD in male soldiers (about 8 percent)' should make people stand up and take notice. [Washington Times].

Beware of Large Sunglasses

Not surprisingly, wearing sunglasses that block your vision is not good for preventing driving accidents.  The UK DailyMail reports on this latest health danger,

"Wide arms and dark lens tints may be the must-haves of the moment, but fashion- conscious women should put safety ahead of style when in control of a car." The Eyecare Trust examined five styles of fashionable sunglasses and found that only two weresuitable for driving.

Trustee Rosie Gavzey said the darkest shades fail to allow a minimum proscribed eight per cent of visible light through and are illegal. Pink tinted lenses can make it difficult to read road signs or spot hazards by distorting colours and wide-armed glasses create blind spots.

Aviator style glasses that curve around the eyes and have slim arms are recommended, along with anti-reflective lenses coloured in neutral brown or grey shades.

Mrs Gavzey said: "Chunky frames could pose a hazard when driving. Motorists need good all-round vision and a visual range of at least 120 degrees.

The article goes on to note that convertible cars put women at risk for skin cancer.   Being fashionable and safe is so difficult. . . .