Physician-Assisted Suicide: Is it Good?

State laws legalizing physician-assisted suicide are growing in number.  Recently, California Governor Jerry Brown signed a bill legalizing the provision of end of life drugs to terminally ill patients.  Governor Brown, who experienced difficulty in deciding whether or not to sign the bill, ultimately decided to sign the bill when he put himself in the shoes of others who were experiencing pain and suffering.  According to Governor Brown, he did not want to deny to terminally ill patients comfort from pain and suffering.

There are two critical benefits associated with physician-assisted suicide.  One of the benefits is that it allows for patient autonomy.  Essentially, individual patients are in control of their death.  In addition, it allows for a patient to choose to end pain and suffering, which is often beneficial for terminally ill patients whose lives could be extended through medical advances, but who would suffer a decline in their quality of life as a result.

Despite these positives, according to detractors of the law, the downfalls to physician-assisted suicide can be seen when you look at the bill from the viewpoint of low-income individuals instead of wealthier people. Critics argue that physician assisted suicide may potentially put pressure on “the poor, the lonely, and the excluded” to end their own lives.  For instance, a study conducted by Oregon’s Public Health Department revealed that only 23% of people cited concerns about pain and suffering as their reason for choosing physician assisted suicide.  However, an overwhelming majority chose physician–assisted suicide because they did not want to lose autonomy, dignity, or be a burden to others.  In addition, in Oregon, where physician-assisted suicide is legal, many low-income individuals qualify for physician-assisted suicide but not basic treatments or hospice care.  Thus, although the intent of this bill was to end pain and suffering, in reality there are some downsides to the law that may impact the poor, lonely, or excluded.


Study Reveals Wealthy People May Have Shorter Wait Times for Transplants

Using data from 33,928 patients, a recent study conducted by researchers at Columbia University revealed that patients on more than one transplant wait-list had shorter wait times.  The study focused on patients who were on multiple heart, lung, liver, or kidney transplant lists, and found that at least in regard to heart transplants, the median wait time for a patient on more than one list was 105 days—as compared to 151 days for a patient on only one list.  Of those patients on multiple transplant lists, the data from the United Network for Organ Sharing revealed that the patients lived in zip codes with a higher than average income.

The researchers opine that the unequal distribution in transplant wait times is due, in part, to the fact that some patients can afford to travel greater distances and put their names on multiple transplant lists. Many of the patients on multiple transplant lists had to travel about 400 miles to the nearest alternative hospital, adding fuel and temporary housing costs.  These expenses make multiple listings more difficult for less well-off patients. In addition, some have argued that hospital administrators may favor patients who have traveled a long way because there is a tendency to feel that “a person [who] has come a long way . . . really ought to [have] the best shot of getting a transplant.” Although this data is revealing, the study has yet to undergo peer review.  However, the data does suggest that the multiple listing system may result in inequitable transplant distributions.


How Sure is Sure? The Ethical Use of Neuroscience in Court

Is neuroscience ready to be used in the courtroom? Judge Jed S. Rakoff, a federal judge for the Southern District of New York, doesn’t think so. Lawyers have been attempting to use neuroscience as evidence with increasing frequency, for purposes such as showing brain dysfunction, proving pain, or acting as a lie detector. However, Rakoff and many other judges are cautious to use this still developing area of science as evidence because “[d]uring the last century, the law [has] embraced science in ways that were inhumane and harmful—and eventually discredited.” An example of harmful science being embraced by the law is the practice of eugenics, which caused several states to allow forced sterilization of women. Another example is lobotomies, which used to be regularly ordered by courts to treat psychiatric patients, some with consent and some without. And as recently as the 1990s, science with no solid basis was used to supposedly recover memories, which led to criminal convictions.

According to concerned judges, this is the danger of allowing neuroscience into evidence, as it can lead to reliance on information which may eventually be discredited, producing unethical results. The effects of these decisions may be permanent, so it is important for science to be very well founded before entering the courtroom; otherwise a fleeting, erroneous scientific theory could have life-long results. “The worst thing that can happen with neuroscience is that it gets into the courtroom before it’s ready,” said Rakoff. This of course begs the question: “how certain must scientists be before their findings can appropriately be used as evidence?” In other words, “how sure is sure?”


Should Children Decide When They Can Die?

Julianna Snow, a five year old from Portland, Oregon with an incurable neurodegenerative illness called Charcot-Marie-Tooth disease, has told her parents she would prefer to go to heaven next time she gets sick rather than the hospital.  Even if doctors are able to save Julianna from her next illness or health scare, Julianna’s long-term prognosis includes being hooked up to a respirator with a very low quality of life.  Julianna’s parents, Michelle Moon and Steve Snow, jumped into the heated debate regarding end of life decision making via Michelle’s blog, where they announced that next time Julianna is sick, they may not take her to the hospital.

Adults with capacity have the right to determine their end of life care.  However, practical and ethical concerns arise with allowing minors to decide their own end of life care.  Medical experts and those familiar with Julianna have various  opinions regarding the issue, but the question remains: to what degree should Julianna’s parents follow her wish to go to heaven (and thus forego life-sustaining care) when she gets sick again?  Bioethicist Art Caplan explains that he does not believe a four year old can understand the concept of death.  Dr. Chris Feudtner, a pediatrician and ethicist, disagrees with Caplan, arguing that only Julianna understands the true ramifications of her progressive neurodegenerative disease.

It seems that when Julianna becomes sick again, Steve, Michelle, and Julianna will make the decision together about whether Julianna should return to the hospital.


UK Doctor Who Admitted to Offering to Arrange a Gender Based Termination Has Been Suspended For Three Months

A 2012 investigation by The Telegraph opened the doors to further inquiry of two UK doctors who faced a private prosecution on gender abortion charges. Under the 1967 Abortion Act, in the UK a pregnancy can only be terminated if two doctors agree that the physical or mental health of the mother or child is in danger, but both doctors must sign and certify that they formed their opinion in good faith. Recent concerns have been raised that the law does not explicitly state that gender selective abortions are illegal. To address this concern, a guidance was issued making it clear that gender-selective abortions are illegal. [1]

In the most recent case, Dr. Prabha Sivaraman and Dr. Palaniappan Rajmohan were summoned to Manchester and Birmingham courts to answer to allegations based on investigations of undercover reporters who accompanied pregnant women to clinics across the country. They filmed Dr. Sivaraman and Dr. Rajmohan agreeing to arrange terminations after the patient revealed that she did not want to continue the pregnancy because of the gender of her unborn child.

Investigation into Dr. Prabha Sivaraman’s conduct was dropped because she was recorded stating: “I don’t ask questions. If you want a termination, you want a termination.” The General Medical Council convened a panel to rule on Dr. Palaniappan Rajmohan’s fitness to practice medicine. The panel found that Dr. Rajmohan agreed to record a false reason to protect the woman who wanted to terminate her pregnancy because of the gender of her child. Instead of expressing this reason, he recorded her reason as “too young for pregnancy.” The panel deemed Dr. Rajmohan’s act of dishonesty as misconduct, and ordered his immediate suspension.


A Potential End to the “Ice Age” of Transplant Organ Transportation

An innovative means for transporting organs may soon debut in the United States. It has the potential to bring organ transportation out of the “ice age.” TransMedics, a company headquartered in Andover, Massachusetts, has developed the Organ Care System, also known as the “heart in a box.” of the system can keep human organs “alive, beating, and breathing” during transport. Rather than transporting disconnected organs via ice cooler, the Organ Care System plugs hearts, lungs, livers, and other organs into a system that keeps blood, air, and other fluids circulating while the organ is maintained at body temperature. Organs – transported alive – have been successfully transplanted up to twenty-four hours after removal, which is roughly six times the current average life span for an organ outside the body. Waleed Hassanein, founder and president of TransMedics, has asserted that as long as an organ remains alive and “perfused in [the Organ Care System] . . . there really is no time limitation [for successful transplantation.]” Even more astonishing is the device’s ability to revive organs from recently deceased patients. Thus far, seventeen people have successfully received hearts from patients whose hearts had stopped beating for thirty minutes or more.

Although the Organ Care System has been in use for many years in Europe and Australia, the FDA has yet to approve its use in the United States. However, this may soon change: TransMedics is scheduled to introduce its system to the FDA on November 18, 2015. If FDA approves the system’s use, the “ice age” of transplant organ transportation may come to and end.


Free Market Response to Drug Price Gouging

As previously reported, in August of this year, Turing Pharmaceuticals purchased the rights to Daraprim, a drug used to treat a variety of conditions, including toxoplasmosis, certain cancers, and malaria. Although the primary agent in Daraprim, pyrimethamine, has been available since 1953 and Daraprim was previously priced at approximately $13.50 per tablet, Turing Pharmaceuticals raised the price of the drug to $750.00 per tablet, sparking outrage across the county. However, in a refreshing turn of events, a recent announcement by generic drug manufacturer Imprimis could lead to a correction in Turing Pharmaceuticals’ pricing for Daraprim.

In an announcement covered by The San Diego Union-Tribune, seen here, generic drug manufacturer Imprimis introduced a competitor drug to Turing’s Daraprim, priced at $1.00 per capsule—a huge benefit for patients who would otherwise be subject to Daraprim’s high cost of $750.00 per capsule.  Having previously cornered the market for the primary agent in Daraprim, pyrimethamine, Turing could seemingly set the price of the drug without fear of competition; however, with Imprimis’ announcement, patients have a more reasonably priced alternative for treatment.  Imprimis additionally announced its intention to manufacture other generic drugs and sell them at more reasonable prices.

Imprimis, in designing the formulation of the generic drugs, uses specific FDA approved ingredients, compounded in FDA inspected compounding operations.  However, because the combined ingredients (or “formulation”) is not FDA-approved, a specific and individualized prescription is required to administer the drug to patients.  This method of operation saves Imprimis time and money by circumventing the lengthy process of seeking FDA approval of the drug’s formulation. Not surprisingly, this practice has received some criticism by providers who desire to prescribe FDA approved formulations.


Human Embryos Genetically Modified

Amid heated debate over the ethics of gene modification, Chinese researchers have been the first to report successfully editing the genome of human embryos. Though non-viable by design, the embryos have heritable traits.  Were edited embryos used in reproduction, the genomic changes could affect future generations.

Researchers at Sun Yat-sen University in Guangzhou, led by Junjiu Huang, utilized the CRISPR/Cas9 gene editing technique to modify the genes that control a rare blood disorder, β-thalassaemia. The process was performed on embryos created for in vitro fertilization that had an extra set of chromosomes, thus precluding live birth.

This research has reignited the debate on gene modification. Critics are concerned that gene modification on human embryos could lead to unsafe and unethical practices. Moreover, the technique that was used has shown inefficiencies – out of 100 embryos, 71 survived and 54 were genetically tested; out of those that were tested only 28 were successfully spliced. Nonetheless, the CRISPR/Cas9 technique is easy to use, and continued research in this area seems likely. Four groups in China are pursuing similar embryonic research.


Planned Parenthood Reacts to Congressional Pressure and Changes Reimbursement Policy

After Planned Parenthood was subjected to recent controversy involving fetal tissue procurement, the organization announced that it would no longer receive reimbursements for fetal tissue donations. Under its former policy, Planned Parenthood received reimbursements for expenses associated with the donation, including costs of procuring and transporting the tissue.

Planned Parenthood’s practice came under scrutiny after an anti-abortion group secretly videotaped a conversation with a Planned Parenthood doctor discussing the process of fetal tissue procurement. An edited video portrayed Planned Parenthood as selling fetal tissue, rather than donating the tissue. Federal law allows fetal tissue to be donated to research facilities, however, organizations cannot profit from such donations. The law only allows for reimbursement of reasonable expenses.

A special Congressional panel investigated Planned Parenthood’s activities. Although the panel did not find any wrongdoing on the part of Planned Parenthood, the national uproar caused by the released video was enough to encourage the organization to review its policy. President of Planned Parenthood, Cecile Richards explained the change in policy as an effort to protect the donation of fetal tissue at their facilities.


Court Battle Over Parents’ Refusal to Continue Chemotherapy For Young Daughter Finally Ends

Sarah Hershberger, now 12, was diagnosed with Leukemia in 2013 and initially began chemotherapy treatment in Ohio. However, she and her parents decided to stop this treatment before its completion because the treatment made Sarah so sick that her parents believed it might actually kill her. Instead, Sarah and her parents decided to pursue more natural treatments using herbs and vitamins. The doctors at Akron Children’s Hospital tried to persuade Sarah’s parents to continue the chemotherapy treatment because had a high chance of survival if she continued the treatment, but if she stopped, her physician believed she could die within a year.  When Sarah did not resume the chemotherapy treatment, the hospital to sought a court appointed guardian to continue the treatment over the objections of Sarah and her parents.

Although a guardian was initially appointed, an Ohio judge has now decided that this action was inappropriate. The statute used by the hospital to appoint the guardian is used when parents are unsuitable to have custody of their children or when the appointment of a guardian would be in the child’s best interests. In making its decision, the Court indicated that the use of this statute to take away medical decision-making power from parents is unprecedented. Moreover, although the family is Amish, the judge found the parents did not make the decision to stop chemotherapy due to religion. Rather, they fully and thoughtfully made the decision in what they believed to be their daughter’s best interests. Additionally, the judge found that a treatment such this, which would be long-term, unsafe, not sure to succeed, and in the public view, was not appropriate to impose over the objection of the parents.

After a long court proceeding, Sarah and her family affirmed their right to choose whether Sarah must continue the chemotherapy recommended by the hospital. Despite the hospital’s initial concerns, Sarah currently appears to be in good health.