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Ethics in Medicine
Written and researched by Bob Murray, PhD
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Tobacco Madness
January 7, 2002
Those who suffer from mental illness smoke cigarettes at astoundingly high rates compared to those without some form of mental illness, according to research published in Psychiatric Times. Between 50% and 80% of those suffering from a major mental illness, such as major depression, bipolar disorder (what used to be called manic depression), generalized anxiety disorder or schizophrenia, smoke.
In all, people with mental illness consume 44% of all cigarettes in the United States, an exceedingly high figure that might surprise even the most sanguine mental health care professional.
Tobacco hits the mentally ill especially hard, according to the authors of the article, J. Wesley Boyd, MD, PhD and Karen Lasser, MD of the Harvard Medical School.
"Roughly one-third of all smokers will die early because of their habit according to the American Lung Association. Living with lung cancer or emphysema is hard enough, but imagine trying to make decisions about treatment options or end-of-life issues in the midst of a dark depression or active psychosis. Those with mental illness are often the least capable of coping with the devastating medical illnesses caused by smoking."
But, according to the authors, often psychiatric units themselves perpetuate the problem. Those units that allow smoking are generally much more popular among patients than smoke-free units and thus generate more revenue. Many of these psychiatric units further use smoking to their advantage by offering cigarette privileges as rewards for good behavior. At one local unit, patients who break minor rules (such as yelling or refusing to participate in groups) are not allowed to go on the next scheduled smoke break. (At that unit, there were six such breaks throughout the day.) Those patients who are assaultive or require restraints are not allowed to smoke for 24 hours.
The tobacco industry also stresses those perceived aspects of smoking that would appeal to people with emotional problems. R.J. Reynolds Tobacco Co. noted the perception among smokers that tobacco "helps perk you up" and "helps you think out problems," as well as providing "anxiety relief," and helping people "gain self-control," "calm down" and "cope with stress."
The authors wonder: Could the tobacco industry be unaware that advertising that highlights the supposed youthful, healthy effects of smoking might be particularly appealing to those with mental illness?
"After all," they muse "the Marlboro Man is the epitome of calm self-assuredness. He does not appear to be anxious, depressed or hallucinating -- though we might wonder if he gets a bit sad riding all alone. Have all of his cowboy buddies passed on to the great prairie in the sky because of their tobacco habits?"
In fact recent studies have shown that the opposite is true and that smoking often precedes the onset of mental illness.
They emphasize that tobacco does not deliver any mental health benefit. In fact, it directly contributes to depression and anxiety. In addition, its physical effects -- emphysema, cancer and heart disease -- can certainly make a person feel blue.
"If the tobacco companies have not hesitated to peddle their goods to children and the Third World, why should we presume they do not also target those with mental illness -- the group that comprises 44% of their market?"
Read more in thePsychiatric Times online
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Australia High on the Mercy Killing List
December 8, 2001
A study has shown that more than a third of surgeons in NSW, Australia, admitted
hastening the deaths of terminally ill patients, mostly without explicit consent.
The anonymous poll of 683 surgeons, published in the Medical Journal of Australia, found that 247 (36%) had administered high doses of painkillers with the intent of bringing death, with half of these respondents saying that there was no direct request from the patient.
Furthermore, 54% of the surgeons said yes to the question of whether it was ever morally acceptable to give terminally ill patients drugs to hasten death. The research, which was conducted by the University of Newcastle, New South Wales, also found that surgeons with a religious faith were nearly 10 times less likely to give life shortening treatment.
The study's author, Dr Charles Douglas, said that intention to shorten life was illegal in Australian law and was defined as euthanasia. He said that 5% of surgeons admitted giving a patient a single lethal injection on their clear request.
"The vast majority of patients were only a few hours or days away from death," he said. "The patient is barely conscious and not in a situation to discuss what happens next."
Dr Philip Nitschke, an euthanasia advocate, who gained international prominence when the Northern Territory briefly legalised euthanasia four years ago, said the results showed that the law should change, as the rate of apparently involuntary euthanasia seemed to be close to that in the Netherlands, where voluntary euthanasia is legal. "There's obviously a need for some form of legislative protection," he said.
Some experts in palliative care have called for immunity from prosecution for surgeons who have hastened death so that they could explain their action to researchers and legislators.
"If doctors identified themselves and were as frank as they were in the anonymous survey, then one third of Australia's general surgeons could be up on murder charges," said Adelaide palliative care specialist Dr Roger Hunt.
But the results were attacked by the Australian Medical Association, pro-life groups, and the Anglican archbishop of Sydney.
"If doctors are doing a Harold Shipman (the British physician convicted of killing literally hundreds of his patients, however they were not mercy killings) out there, we want them to go to prison," said the association's ethics chairman, Trevor Mudge, who rejected the immunity call. "Some treatments that improve the quality of life will hasten death, this should be seen not as a bonus but as an unfortunate byproduct."
Personally I believe that the Kervorkians and the Nitschkes of this world are extremely dangerous. As a psychologist I can attest to the fact that a mood disorder such as depression can somatize -- mimic a physical illness. It can even mimic a potentially life-threatening one such as cancer. Since less than half of all physicians (according to a recent European study) are aware of even the major symptoms of depression, many people in Australia, Holland (where euthanasia is legal), and elsewhere, are probably being put to death simply because they are depressed and incorrectly diagnosed. BM
Read more in the British Journal of Medicine online
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Drugs Firms' Pressure 'Risks Lives'
September 21, 2001
Patient safety is under threat because commercial interests are skewing the results of drug trials, say the editors of some of the world's top medical journals.
Eleven publications say that in some cases the benefits of drugs have been hyped in research papers, and side effects disguised. This could lead to doctors prescribing unsuitable drugs for their patients, they claim.
The influential journals have threatened that unless trials can be proved to be independent, the results will not be published in their journals to protect patients. The publications include the Lancet, the Journal of the American Medical Association, the Canadian Medical Association Journal, and the Dutch Journal of Medicine.
Dr Richard Horton, the editor of the Lancet, one of the UK's top journals, said all the editors had seen examples of trials where the best interests of patients had been pushed aside by the interests of the drug companies. In one case he cited, patients died after a potentially fatal side effect was allegedly discounted by the study authors.
However, the Association of British Pharmaceutical Industry, quoted in the BBC News Online, said that the profession in the UK had high ethical standards, and said it too supported an independent approach.
Dr Horton said new drugs had in some cases been manipulated and hyped out of proportion by the companies. Nine out of 10 reviewers say the papers they receive have been hyped in favor of the drugs and half have to be rejected. Others need to be substantially rewritten before they can be published.
"All of us who signed this had seen instances of where cash interests had been put before patients" he told the BBC. "There are examples of exaggerated benefits and suppressing and avoiding the adverse effects of drugs."
Dr Horton said that it was recognized that clinical trials are expensive and drug company money needed, the average cost of bringing a new drug to the market in the USA is about $500m. But he said it was important that drug companies investing in trials should take a back seat.
"We would not have any medical advances if it was not for pharmaceutical companies investing in drugs, but at the same time they have to put the interests of patients first."
The International Committee of Medical Journal Editors (ICMJE) has now strengthened its guidelines to restrict the publication of those studies where they feel the objectivity is compromised.
"We will not review or publish articles based on studies that are conducted under conditions that allow the sponsor to have sole control of the data or to withhold publication."
Read more in BBC News
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Heart Joins Head in Moral Maze
September 21, 2001
If five people are trapped on a railway track and a train is approaching, is it morally right to divert the train onto another track where there is only one person? Most people would say yes. Would it be right to push a person onto the track to prevent the train from hitting the other five? This time, most people would say no.The different responses puzzle philosophers, because the principle -- sacrifice one life to save five -- is the same in both cases.
Magnetic resonance images now show that our brains process the two dilemmas in fundamentally different ways, using brain regions responsible for emotion only in the second situation.
"We've known almost nothing about how the brain handles moral dilemmas," says psychologist Jonathan Cohen, who conducted the experiment with colleagues at Princeton University in New Jersey. "Now it appears that when people make moral decisions, emotional responses play as much of a role as logical analyses."
When study participants made moral decisions about situations that have a personal element, such as throwing people off a sinking lifeboat, activity soared in four parts of the brain involved in processing emotion. Meanwhile, it sank in three regions associated with working memory, which stores and processes information in the short term. The reverse happened when subjects judged less personal moral dilemmas, such as keeping the money found in a lost wallet, or considered questions that were not moral issues, such as whether to travel by bus or train in a given situation.
"This is fascinating research, which brings emotion firmly into the process of reasoning itself," says Helen Haste, an expert on the psychology of morality at the University of Bath in England. Many researchers have regarded moral reasoning as a purely analytical process, and deemed emotion as "something that gets in the way of reason", she says.
Perhaps the most crucial finding of the study, says Joshua Greene, who led the Princeton study, was that people took significantly longer to conclude that it was appropriate to push a person in front of the train than to decide it was inappropriate.
"The people who said it was appropriate had to fight their emotions, so they were more hesitant," he says. "This says that emotion isn't just incidental, but really exerts a force on people's judgements."
Read more in Nature
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House Backs Ban on Human Cloning for Any Objective
August 8, 2001
Human cloning is in the news and, whether you agree with it or not, seems to be rushing upon us with an inevitably which it's opponents see as frightening.
There are two issues at stake: human cloning for therapeutic purposes -- to use the resultant tissue for pharmaceutical research (which, for example, the UK allows) -- and cloning for the purpose of helping couples with fertility problems.
The US House of Representatives has voted, by a wide majority, to ban cloning for any purposes, and the Senate will probably follow suit.
The 265-to-162 vote came after lawmakers rejected an alternative measure that would have prohibited making babies by cloning while leaving open the door for "therapeutic cloning" experiments in which scientists would create embryos that could be used to treat disease.
The bill the House adopted, which is backed by President Bush, would not only prohibit it, but would also outlaw the sale of treatments developed from it. "I think the House spoke very, very loudly today that this is morally and ethically inappropriate," said Representative Dave Weldon, a Florida Republican who was the bill's chief sponsor. "It clearly sends a message that there is a place we don't want to go, and that is the manufacture of scientific embryos for research."
The cloning debate is tangled up with another scientific controversy steeped in politics, that of embryonic stem cell research. The House vote comes as President Bush is weighing whether to permit federal financing of embryonic stem cell studies, and it complicates both the politics of the debate and the business of stem cell science.
The vote against cloning does not dim the prospects for Congress to approve federally financed stem cell research should President Bush come out against it. Lawmakers say that is because stem cell research, which typically involves using embryos that would otherwise be discarded by fertility clinics, does not seem as extreme to many people as therapeutic cloning.
Stem cells are extracted from human embryos, tiny clusters of cells that are destroyed in the process. The cells are the building blocks of all the body's tissues, and so they may be useful for repairing or replacing damaged organs. Researchers see therapeutic cloning, which might provide treatments that would be an exact tissue match for patients, as the most promising avenue for stem cell research.
Despite the US stance, doctors in Italy are preparing to begin human cloning for reproductive purposes. Two hundred couples are reported to have been selected to take part in a human cloning project run by an Italian embryologist. Dr Severino Antinori said he intended to go ahead with attempts to produce human clones, after announcing the successful cloning of 10 mice.
Dr Antinori, earned international fame in 1994 for enabling a 62-year-old woman to have a baby.
The technique he will use is similar to that used to produce Dolly the sheep, the first vertebrate clone created from the cell of an adult animal. It involves injecting genetic material from an infertile father into the mother's egg, which is then implanted in the woman's uterus. The resulting child would have the same physical characteristics as the father -- and the infertile parents would not have to rely on sperm donors.
Dr Antinori, who runs a clinic in Rome that helps infertile couples, has been warned by scientists in Japan and the United States that he risks "creating monsters." But he insists that these fears are exaggerated, and says he hopes to start the program in November.
Scientists involved in the successful birth of Dolly the sheep say the high level of failure and foetal abnormality in their work shows that applying the same technique to humans would be irresponsible. Professor Ian Wilmut, of the Roslin Institute, told the BBC he would be very concerned. "The most likely outcome of any attempt to produce a human clone at present would be late abortion, birth of dead children or, perhaps worse, the birth of children who are abnormal."
I understand that at least one American doctor will be working with Dr Antinori. The pressure from infertile couples may well force the UK and probably the US as well to permit reproductive cloning in the future. It seems to me that infertility is perhaps Nature's last throw at trying to control the explosion in human population and there may, therefore, be an ethical problem with all attempts of reverse it. BM
Read more in theNew York Times
And on BBC News
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Life-or-death Guidance 'Illegal'
August 8, 2001
Key guidelines on when doctors can stop treating terminally-ill patients could be flawed or even unlawful, claim leading doctors.
The British General Medical Council (GMC), which is currently drawing up the guidance, has not given people enough chance to point out these potential problems, they say. The accusations were levelled in a letter to the Daily Telegraph co-signed by several eminent doctors.
The doctors say the draft guidance, published prior to the consultation period, appears to be legally flawed. It states that while in most cases prolonging life is in the patient's best interests, treatments should not be excessively burdensome or "disproportionate in relation to the expected benefits." It continues: "Withholding or withdrawing life-prolonging treatment is in the best interests of a patient when there is no net benefit to the patient of providing the treatment."
However, in the Telegraph letter, the doctors write: "Currently, doctors consider patients' best interests clinically when treating them, but the guidance seems to encourage subjective 'quality of life' considerations that are worryingly vague."
The guidance also appears to allow the withdrawing and withholding of fluids by tube to non-dying patients so as to cause their death. That, of course, is, and should remain, unlawful. "No patient should ever be allowed to die through dehydration. The patient's thirst should always be relieved."
The idea of letting anyone die of thirst is indeed appalling. But there is a larger question here, perhaps. It's hard for doctors to admit that there is nothing more they can do for a dying patient. Perhaps the real issue is how we, as a society, view death. We seem to have lost sight of the idea of a 'harmonious death,' one where the dying person is made as comfortable as possible and where he or she is surrounded by friends and where the process is endowed with ritual. The issue, then is not how long the patient is kept alive by 'heroic medicine' but whether he or she dies in harmony. In this sense the priest, or shaman, has a vital role to play. An old guru of mine once said that no one deserved to die alone. BM
Read more on BBC News
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Make That A Boy Please
July 10, 2001
A scientific breakthrough that can virtually guarantee the sex of a foetus has raised concerns about safety and possible abuse. There are fears that the technology could be abused by people wanting to determine their child's sex for purely social reasons.
One eminent British fertility expert, Lord Winston, warned parents against using the new procedure, which he said could cause damage to the unborn child.
The new technique involves separating out sperm that will produce a female embryo. This can be done because they carry more genetic material than those that will produce males. There are other gender selection techniques, but this is more accurate, and does not rely on discarding already fertilised embryos.
US researchers claim their method is accurate on nine out of 10 occasions, and say that their technique could help couples to avoid passing on genetic illnesses, which usually affect only boys. It is the contents of the sperm that decide whether a baby will be male or female. A sperm that carries a Y chromosome will produce a boy, while one that carries an X chromosome will produce a girl.
The key difference between the two is that the X chromosome is substantially larger than the Y chromosome -- carrying 2.8% more DNA. The MicroSort technique, developed at the Genetics and IVF Institute in Fairfax, Virginia, exploits this difference.
Dr Harvey Stern, presenting the team's work at the European Society of Human Reproduction and Embryology congress in Lausanne, said the device was currently undergoing a clinical trial, but experiments so far had been highly successful.
He said: "We were able to be unambiguous in assigning gender in 90% of the 284 embryos. "Of these, 92% were female and 8% were male. It substantially increases the chance of a couple having a child of a particular gender." Researchers would be keen to stress that the device should not simply be seen as a frivolous "lifestyle" technique for those who would prefer a female child, perhaps because they had existing male children.
Does anyone really believe that the Fairfax method will not be used for 'frivolous' reasons? Of course it may eventually cut down on the huge number of female abortions in China and other Asian countries. There really are some procedures which should be banned because though they might be useful to a few unfortunate people, they cannot be effectively policed. BM
Read more on the BBC News
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Babies Without Fathers
July 10, 2001
Scientists in Australia have found a way to fertilise eggs using genetic material from any cell in the body -- not just sperm. Theoretically, it could mean that lesbian couples could give birth to a baby girl without the need for a father. Women do not carry the genetic information required to make a boy.
The technique has been developed by Dr Orly Lacham-Kaplan, from Monash University in Melbourne.
According to Dr Lacham-Kaplan, her team had been able to successfully fertilise mice eggs in lab cultures using other cells in the body known as somatic cells. Until now this has not been possible because somatic cells contain two sets of chromosomes, while sperm cells only contain one set. The Monash team used chemical techniques to get rid of the spare set of chromosomes.
However, they will not know if the embryos were viable until they were transferred to foster mothers for further development. "We will then have to wait to see if any live and healthy babies are born following those transfers. "Within the next six to eight months I believe we will have the answer, and see whether this technology can go further and be used maybe in clinical aspects."
Dr Lacham-Kaplan said she had started her work to help men who were unable to have children because they had no sperm, or germ cells with the potential to become sperm.
But she added: "Theoretically, we can use somatic cells from a female to produce the same embryo. So two women who wish to have their own biological children would be able maybe to use this technology to achieve that aim."
Why do we spend so much time and resources creating ways to trick Nature into making more of us? I remember one couple I was working with, who had a shaky relationship, a child diagnosed with ADHD and in which the woman had a chronic illness. Yet they both said they wanted a second child. I could understand the woman's strong desire to conceive again -- hormones do that. But when I asked the man why he wanted a second child with his current wife (he already had two from a former marriage) he replied, "Two is a good number." After much therapy, the couple decided not to have a second child, and both reported their relief, years later, that they did not.
Perhaps when a couple can't conceive, one or other of their bodies knows something the conscious mind doesn't. Or perhaps the earth knows something we consciously don't.
I would like to see all our efforts as a species concentrated on making the lives we do bring into this world happy and harmonious, rather than yielding to the social pressure to simply have more. By the way, if we lived in small communities as our hunter-gatherer forbears did, we would all have enough babies and children to enjoy, and no one individual or nuclear family would be over-burdened with the responsibility.
When will the madness end? AF
Read more on BBC News
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'Fat Tax' Proposed
'Sin tax' has traditionally been levied on alcohol and cigarettes, often as a way of reducing consumption. Now nutritionists in New Zealand are proposing to add eating fatty foods to the list of grave sins that must be taxed. Pass me a (presently untaxed) cookie while I consider the situation.
Apparently the Kiwis have woken up to the fact that 50% of the population is overweight. And this despite their pride in their country's sporting heritage and outdoor lifestyle. More than 1,000 people die each year from obesity -- that's more than double the annual road death toll.
The report's authors include the Heart Foundation, diabetes experts and the Cancer Society. They are now recommending a special tax on sugary or fatty foods, and they want to see more information on the nutritious content of servings in cafeterias and restaurants.
The group says the current methods -- making people feel bad about what they eat -- are not particularly successful. Not surprisingly, the recommendations have received a lukewarm response, at least on radio phone-ins. Welfare groups say many low-income families rely on fast food because it is the cheapest available. They say a 'fat tax' will only penalize those who can least afford it.
Actually quite a lot of recent research shows that well-meaning education programs fail to achieve their goals. One study (released June 14) showed that gay men given intensive education about the dangers of 'unsafe sex' were more likely to indulge in risky practices than a control group who didn't have the coaching. Sex education programs in schools ditto. The failure of the 'Just Say No' and 'DARE' campaigns are further cases in point. More striking is the fact that the latest figures (released June 15) from Australia show that while, as a result of some particularly graphic and strident education programs, cigarette smoking has lowered by 25% over the last few years, marijuana smoking has increased proportionately. What none of these campaigns takes into account are the underlying biochemical/social/familial/emotional problems at the root of all these problems. These fundamental difficulties can only be treated by programs or therapies that take all these these factors into account, such as the Uplift Program. BM.
Read more in BBC News
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When Can Doctors Kill?
March 17, 2001
The euthanasia debate is heating up in Europe again with bills before the Dutch and Belgian parliaments to liberalize the conditions under which doctors can kill their patients.
The Dutch bill would give anyone over the age of 12 the right to ask their doctor to kill them and if they are over 16 they could do this without parental consent. The Dutch would maintain their rule that insists that two physicians concur before a patient can be put to death.
The Belgian law would go further and allow euthanasia on the diagnosis of a single doctor.
However a reaction to these measures has begun. Two German MEPs (Members of the European Parliament) are now trying to mobilise European public opinion against the new legislation. Dr Peter Liese, the chairman of the Christian Democratic working group for bioethics in the European parliament, and his compatriot, Hiltrud Breyer, the Green Party's spokeswoman on the temporary committee for human genetics, are calling for alternative treatment for people at the end of their lives. They support each patient's right to reject life-prolonging measures such as artificial respiration. But they insist that this is totally different from active euthanasia. "If the state starts to allow medical doctors to give pills or an injection to their patients with the sole aim of killing the patients, the misuse of this method is inevitable," they pointed out.
Instead, they want increased EU and national funds for research into effective pain relief and improved palliative care. They are also looking for political support from the European parliament to put pressure on national authorities to provide more hospices.
The danger of doctor-assisted suicide, especially when only one physician is involved, has been shown up most recently in the case of convicted mass-murderer Dr Kevorkian ('Dr Death') in the US. He claimed that he was merely helping terminally-ill people to die. However a study by the University of Florida published last December showed that the majority of his victims were not terminally ill but were suffering from depression. Depression can produce terminal-like symptoms which can 'miraculously' clear when the depression itself is alleviated. I personally have witnessed this with patients of mine who had been diagnosed by their physicians as having terminal cancer or advanced lupus. BM
Read more in the British Medical Journal
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About the Author
Dr Bob Murray is a widely published psychologist and expert on emotional health and optimal relationships. Together with his wife and long-term collaborator Alicia Fortinberry, he is founder of the highly successful Uplift Program, and author of Raising an Optimistic Child (McGraw-Hill, 2006) and Creating Optimism (McGraw-Hill, 2004).
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