30 years: In Vitro Fertilization,Bioethics and Public Health

My own first child is a little older than Louise Brown, the first child born from in vitro fertilization (IVF). This incidental pioneer celebrates her 30th birthday this month, calling for reviews and editorials on what her birth has meant to culture and to individuals, such as this one from the UK's Telegraph.

It's good to hear that Ms. Brown has a child of her own, "naturally conceived" with her husband. Full circle.

Human-pig embryo approved in UK

The "cybrid" or hybrid human-animal embryos are created in the laboratory by Somatic Cell Nuclear Transplantation, using emptied eggs from animals and the nuclear and cellular DNA from humans.. We know that there are currently experiments on-going with the human embryos made using emptied cow eggs (more on the "ease" of making these embryos, here), and now the British have authorized the development of pig-human embryos.

The experimenters admit that the problem will be achieving embryos and embryonic stem cells that do not contain DNA left from the egg. Proving the purity and "human-ness" of the stem cells will be a complication that I do not believe they will be able to overcome, at least for transplantation into humans, except possibly in the case of severe, last-hope disease and trauma.

The ethical debates about xeno-transplants and treatments using living organs, cells and tissues from animals carry the risks of transmitting animal diseases that humans have no immunity for and the development of new strains of disease that cross species lines. Ethicists have predicted that at least the early patients will have to live their lives in isolation at the worst, and have life-long surveillance at the best. (more on the debate, here and here.)

However, the researchers will probably be able to develop other uses, such as the early warning chemical weapon detection systems that are being developed by our own military, using human embryonic stem cells.

Rather than humanitarian and medical hope, I believe that time will show us that the research is the result of pure greed, with each lab hoping to come up with a product that can be patented and sold. I'm disappointed that the courts and "ethics" bodies in the US and UK have allowed these patents of human organisms. The drive to "create" new human cells and artifacts using human DNA is the logical outcome.

Medicare, IRS kill doctors by alphabet soup

There's this number called the "NPI." The CMS (Center for Medicare and Medicaid or Can't Manage S(tuff))mandated that any one and any corporation that bills them (for services already done, mind you) needed to add this number, the "National Provider Identifier," by May 23 of this year. (Need I report that quite a few doctors haven't been getting paid properly since? ) Well, out of the blue, the PTB (Powers that Be) sent down a little notice that the names associated with the NPI must now be identical to the ones that the IRS (Infernal Internal Revenue Service) has on file.

The NPI is in addition to the "UPIN" (Unique Provider Identifier Number) the DEA (Drug Enforcement Agency) number, a whole caboodle of state and insurance "identifiers," and that pesky identifier that your mother, father, and husband gave you: your name.

The NPI also had to be acquired for any and each partnership or practice. Some people had one for themselves and one for their practice. Some did not receive their number for months. And, some were unable to get paid even with all the right numbers in the right place.

Now, many will have to start the application process all over if there's a period after the "M" in "M.D." or a space between the letters in their IRS files.

Here's more from "Health IT News:"

Healthcare IT News
By Diana Manos, Senior Editor

06/17/08

WASHINGTON - Just when doctors thought things couldn't get much worse, experts say, the Centers for Medicare & Medicaid Services has thrown another wrench into the already difficult transition to using National Provider Identifiers.

According to a June 11 CMS announcement, doctors will have to reconcile their NPI data with their IRS legal name data in order to get paid.

According to billing experts, this is a disaster waiting to happen. Every aspect of the data must match, including the exact spelling of names, the use of initials and even blank spaces in the data. The slightest discrepancy could send Medicare claims back to the drawing board. Don't go getting married!

After a year-long contingency period, the use of NPIs was required by CMS as of May 23. Both before and since that deadline, doctors have had difficulty getting paid due to a host of complications with CMS and clearinghouse systems, experts say.

Cyndee Weston, executive director of the American Medical Billing Association, said the IRS matching requirement "has blindsided the whole industry."

Weston, who works with small billing companies that submit claims for doctors, said many doctors who began using their NPI identifiers before the deadline have still not received Medicare reimbursements.

"This is going to affect all the doctors we work for. It's going to kill their practices," Weston said.

"I think we haven't seen the worst of this yet. I think we're going to see a big uprising if this continues. No way around it."

Martin Jensen, chief operating officer and chief analyst at the Healthcare IT Transition Group, a consulting group specializing in helping doctors get paid, said physicians aren't getting consistent answers from the CMS or its intermediaries as to what's blocking the claims. The added stress of matching NPI to IRS data is going to compound their troubles.

"This IRS thing is very immediate and one we didn't anticipate," Jensen said. "It's definitely going to set off a cascade of mismatches to data."

The answer most physicians are getting from CMS is to start over with a new NPI enrollment. This could take months, Jensen said. Even doctors who have successfully had their claims paid under NPI could be forced to start over if their IRS data doesn't match, he added.

Are you a provider experiencing difficulty getting paid under NPI? Share your experiences with Senior Editor Diana Manos at diana.manos@medtechpublishing.com.

I don't believe that doctors will actually quit work. Who can, unless our spouse has a good income or we were independently wealthy to begin. What's going to happen is that many more docs will "opt out," or quit accepting Medicare or Medicaid. With the threatened 15%- 20% cut looming over our heads, the extra work and uncertain payment, along with the threat of legal consequences and now no payment) if one comma, period, or space is out of place, I'm not sure I would trust a doc stupid enough to try to play the game.

FDA goes after fraudulent cancer cures

We were just talking about this.

The Washington Post reports

Neil Baker, a retired maker of truck canopies in Helena, Mont., fills about two orders a month for E-Mune through his company, Herbal Remission. It is made from bloodroot, a plant that contains sanguinarine, which has been studied for possible anti-tumor activity. He says one customer's melanoma was cured.

"I really don't know a whole lot about it. All I know is it works," said Baker, 63. "As far as I'm concerned, humanity should have it. But if the FDA doesn't like it, that's okay with me, too."

The FDA's list of "fake cancer cures" is at http://www.fda.gov/bbs/topics/factsheets/fakecancercures.html.

New Bioedge edition available

The weekly newsletter, Bioedge, from the land down under is one of the better bioethics/biotechnology on-line newsletters.

Readers who consider the pro-life movement mainly as a US political matter, may be surprised by the existence of Bioedge, since it is pro-life. The publishers' aim is to:

* to promote evidence-based ethics in medicine
* to promote compassion in medical care
* to highlight the fact that medical excellence is not possible without ethical principles
* to provide high-quality up-to-date information and commentary on bioethics
* to facilitate the participation of health professionals in policy debates on bioethics

This week's headlines include

"Stem cell scientists seek to shed snake oil image"

"California euthanasia lobby scores victory"

"Nature attacks ‘human dignity’"

"Surprise on operating table"

"US Catholic bishops reject embryonic stem cell research"

Coffee drinkers live longer

If true, I may live forever.

According to the Washington Post,

The researchers found that women who drank two or three cups of caffeinated coffee daily had a 25 percent lower risk of death from heart disease during the follow-up (from 1980 to 2004) than non-drinkers. Women also had an 18 percent lower death risk from a cause other than cancer or heart disease compared with non-coffee drinkers.

For men, drinking two to three cups of caffeinated coffee daily was a "wash" -- not associated with either an increased or a decreased risk of death during the follow up, from 1986 to 2004.

The lower death rate was mainly due to a lower risk for heart disease deaths, the researchers found, while no link was discovered for coffee drinking and cancer deaths. The relationship did not seem to be directly related to caffeine, according to the researchers, since those who drank decaf also had a lower death rate than those who didn't drink either kind of coffee.

Election year pro-abortion push

If you don't want your child to suffer, you don't choose Partial Birth Abortion (Intact Dilation and Extraction or "D&X") and you certainly shouldn't complain about State laws concerning prevention of fetal pain during the abortion.

msnbc.com and Self Magazine have teamed up to discuss "When there is no good choice."

In the story, we read about abortions - one at 22 weeks and and one at 30 weeks pregnancy, after two mothers learn that their babies have severe birth defects. While the story spends a lot of space trying to explain that the mothers are having the abortions because they don't want their babies to suffer, the story condemns laws requiring anesthesia, informing the mothers that their children may feel pain during the procedure, or mandating lethal injections to kill the child before dismembering him or her. Of course, we are told how wrong it is to call "D&X" "partial birth abortion," or to ban the procedure itself.

This is a story about the politics of an election year, written to tug on our heart strings rather than inform.

Obviously, I am pro-life, and so, I must be one of those the article calls "anti-abortion." The story claims that I "demonize" the mothers who have abortions at 28 weeks, and mentions that because of George Bush, the Republicans, and "red staters," these women have troubles and the doctors claim that they worry about being charged with breaking the law. However, each woman does abort her child.

The author doesn't seem to notice the irony that she is practicing demonization, herself.

The good news is that the article reports on perinatal hospice, now available across the country:

Today some 60 U.S. hospitals, hospices and crisis pregnancy clinics offer perinatal hospice services; in Minnesota, women seeking to abort fetuses with fatal anomalies are required by law to be informed about hospice as an alternative. “Women appreciate the grieving process and being able to spend time with their babies,” says Dr. Calhoun, vice chair of obstetrics and gynecology at West Virginia University School of Medicine in Charleston. “Perinatal hospice gives women an alternative that is a better choice than abortion.”

Everyone else does it

The American Medical Association and the American Medical Student Association are both up in arms about contact between drug companies and other vendors and doctors and medical students. And yet, no one complains when a New York Times story about the fuss contains advertising. (Free registration required -- is "free" anything undue influence?)

I've said it before, perhaps I can be bought, but not for a pen, some samples or lunch.

Meningitis damage repaired with adult stem cells

A 20 year old young man from Bedford, Texas was about to lose his arms and legs due to the clotting of blood in his vessels caused by meningitis but no longer.

The treatment involved doctors and technicians at Parkland Hospital in Dallas, Florida, Israel and the Dominican Republic, and one aunt with a computer search.

(While it's wonderful that this young man was rescued, I can't help but wonder how many other experiments are going on in other countries, led by US doctors. Remember that Dr. Wilkerson of Houston did his first experiments using adult stem cells in Brazil.)

From the Fort Worth Star Telegram (Free subscription required):

Lampkin's medical odyssey has taken him from his home in Bedford to a hospital in an island country for a treatment the U.S. Food and Drug Administration has not approved.

Sudden onset
It began when Lampkin, a freshman attending Cisco Junior College on an athletic scholarship, returned home for spring break.

That Friday he was fine. But on Saturday while visiting friends, he complained of having a headache and went to bed early, said Michelle Gideon, Lampkin's godmother.

The next morning -- Easter Sunday -- she found him lying on a bedroom floor.

"One side of his face looked totally normal, but the other side was swollen and looked like he had chickenpox," she recalled.

Lampkin was rushed to Harris Methodist H.E.B. Hospital, where he was treated for bacterial meningitis. Those chickenpoxlike spots were signs of clots cutting off blood flow.

Antibiotics helped stabilize Lampkin, who was transferred to Parkland Memorial Hospital in Dallas.

There doctors planned to amputate his legs at the knees and his arms at the elbows.

But an aunt searched the Internet for other treatments and found Grekos, who was using adult stem cells to stimulate tissue regrowth, improve circulation and reduce diabetic amputation rates. Grekos, director of cardiology and vascular disease at Regenocyte Therapeutic in Florida, flew to Dallas to escort Lampkin and his mother to the facility.

"If there was any hope of helping this young man we wanted to offer it," he said.

Once Lampkin was in Florida, his blood was drawn and sent to a lab in Israel.

Although it was Passover and the lab staffers were on vacation, they agreed to process the blood, Grekos said. The cells were then replicated into millions of super cells that Grekos' company has branded "Renocytes." The cells can become almost any type of new cell or tissue, he said.

I'm quoted in Texas Monthly

Over the weekend, at the annual convention of the Texas Medical Association, a friend said that she'd read my quote in "Texas Monthly." I assumed she meant an old article in Texas Medicine, the journal of the Texas Medical Association. I was wrong. (And, maybe now I know why I can't get appointed to any of the TMA Councils or Committees!)

In an article titled, "Faith, Hope and Chastity," in the very liberal Texas Monthly the author (without contacting me at all, by the way) used a statement that I made at a 2004 Texas School Board hearing on the content of high school textbooks on sex education.

The board met to consider these textbooks in July and September of 2004. More than one hundred people testified or submitted written testimony. Those who testified in person were given three minutes each to make their case. According to Gordon Crofoot, a specialist in HIV and STD treatment and research, many of the board members appeared totally uninterested in his testimony. Crofoot cares for about one thousand patients in his practice in Houston and is currently seeing more young patients with HIV than he has in his 31 years of practice.

“These textbooks do not meet the criteria and are factually and scientifically incorrect in what they say,” he told the board, “but their major fault is in what they don’t say and the resulting consequences. . . . If we do nothing [about STDs], the direct cost over the next ten years would be $10.6 billion. Comprehensive sex education programs might reduce this cost by fifty percent. Can Texas afford this cost?”

Crofoot was cut off when his three minutes were up. He offered to answer any questions. The board had none. Later in the day, he watched as Beverly Nuckols, a family doctor in New Braunfels opposed to comprehensive sex ed, was asked about the implications of human papillomavirus for men. She answered that HPV affected women differently than men before stating her position that condom instruction, in her experience as a family doctor, would do little good. “Yesterday I saw a boy who had had three partners in the last month,” she said. “He’s had twenty-two partners. He’s eighteen. He uses condoms every time. Unfortunately, a lot of the times he’s drunk and so they break or they don’t work. I mean, condoms are not a solution for teenagers outside of monogamous relationships. They don’t use them right even if we teach them.”

I'm not quite sure why I was chosen as the representative of those who "opposed comprehensive sex ed." I can't quite remember telling the story, but I probably did -- however, I don't think I would say, "I mean . . ." In order to read it in the journal, you'd have to turn to the "continued on page 200-something." However, I believe that the story was to refute testimony that high school boys and girls should be taught that condoms are the answer to all risk from the consequences of sex. My more common story is to note that condoms are more likely to be used correctly by couples in a monogamous relationship, that couples get better as time goes on, and that if a hundred couples use condoms to prevent pregnancy, 11 of them will get pregnant within a year.

The part that I remember addressing was a comment from a nurse practitioner who stated that there was no risk of contracting the Human Papilloma Virus for a girl, if the male wore a condom. The concern, according to her, is the infection of the girl's cervix. This was about the time that the public was becoming aware that cervical cancer is caused by HPV 99% of the time. According to the nurse, the tip of the penis when covered by the condom wouldn't actually touch the cervix. I felt compelled to delicately explain that the most common human sexual activity involves ins and outs, and that there is much more contact and potential for spread of the virus to all of the male and female genitalia -- except for the parts actually covered by the condom.

Let me correct one thing: I'm not against comprehensive sex education. I disagree with some people about the definition of "comprehensive," and believe that anything beyond the basics of very boring biology - the medical and legal responsibilities of human sexual activity - ought to be vetted by the parents in the local school districts. The school is not the place to teach methods and techniques and condoms are not the panacea they're far too often made out to be.

I do believe that the State (schools) should encourage sex within monogamous marriage, since that is the healthiest for individuals, families and their children, and for the taxpayer. While some people do very well in different arrangements, it takes a lot more work and the risks are far greater.

Add portable hearts to end of life care dilemma

From the Washington Post:

Surgeons at more than 60 centers in the United States are now implanting at least 1,000 LVADs each year. Smaller, more durable and more easily implanted versions are being developed, including one that was approved just this week. With at least 5 million Americans suffering from heart failure, 550,000 new cases being diagnosed each year, only about 2,000 hearts available for transplant each year, and Medicare willing to pay for LVADs (at a typical cost of $200,000), experts predict the number will soar.

"We are at the cusp of a rapid expansion of this type of therapy," said Park, who estimates that within the next five years, 10,000 Americans annually may get the pumps.

Add one more decision to the mix -- I'm afraid that in practical terms, the decision will be whether to even give the patient a trial of LVAD or not.

I disagree with the bioethicist (there's a link to the Hastings Center article in pdf, here) who says that the pump becomes a part of the patient's body. It's still a piece of artificially introduced technology and medical treatment that requires maintenance and battery charges -- would we replace it if we had a biological heart? There's also the very fact that we're able to discuss "powering down" the motor, which makes it different from a "part of the patient's body."


I know of a patient who, for about a month, has worn a "Life Vest," a portable defibrillator while waiting for the implantation of a demand defibrillator/pacemaker. Even the interventional cardiologists hadn't seen one before and came to check it out. I've had patients ask to have an implanted demand defibrillator turned off because it was firing so often - it was like a kick in the chest each time their heart stopped beating.

The Texas Medical Association has a resolution sent forward by one of the County Medical Associations concerning end of life care. It asks for a study to determine reliable scales or ratings for health status based on objective criteria such as labs, age, history. The goal would be ending Federal and State insurance (Medicare, Tricare, Medicaid) funding for any care other than Palliative once a patient meets certain criteria. The resolution wouldn't restrict private funding -- but so far, Medicare has put pressure on docs who charge patients outside their payment limits.

3 times over the past week, I've heard colleagues comment on the expenses related to current standards of health care - and some abuses, such as sending the patient from the nursing home to the doctor's office by ambulance. Each mentioned that the expenses of these patients will bankrupt "the system."

Frankly, I don't want the State to mandate that I can't treat anymore than I like telling me that I have to treat, if the number crunching and check boxes don't fit with my medical judgment.

(But I did realize how much of an aversion I have to wearing a vest that can give me an electrical jolt, and that I have to keep adjusted. I would probably be a little compulsive about adjusting it, and have to check out whether it [still] works, getting an extra shock each time.

Oklahoma abortion Bill survives Governor's veto

The Oklahoma State Legislature has overturned Governor Henry's veto of an "omnibus" bill containing abortion regulations. (The veto is explained at the United Kingdom site of Medical News Today. Besides gives the best definition of human embryo that I've seen in legislation:

“Human embryo” means a human organism that is derived by fertilization, parthenogenesis, cloning, or any other means from one or more human gametes or human diploid cells.

Pro-abortion groups are concerned that the bill requires the facility doctor to perform an ultrasound before every abortion, that the girl or woman be allowed to see it, and that the results be explained to her. Not only is there a requirement to post a notice in the facility informing the women and girls that it is "against the law for anyone, regardless of his or her relationship to you, to force you to have an abortion" and the abortionist evidently must actually speak the words out loud before each abortion!

Called the "Freedom of Conscience Act," (The text is here, in a Word document) the bill offers protection to any medical professional who refuses to act in a way that goes against his or her conscience.


The best news article that I've found is here, at the "Daily Women's Health Policy Report" of the National Partnership for Women and Families, a group I'd never heard of before. It appears that the main focus has been legislation to protect women in the workplace.
Robert Cole, an Oklahoma native, writing for Associated Content, has explained the bill in this article. Here's an article from The Feminist Majority, with good links.

Ironically, Democratic Presidential Candidate, Barack Obama, used the objection to abortion by the Senator from Oklahoma, Senator and Obstetrician Tom Coburn, to justify his relationship with the Weatherman bomb-building conspirator and now-college professor, William Ayers. (Ayers is the man who was quoted in the New York Times on September 11, 2001 as regretting that he did not do enough bombing and fighting the US government in the early '70's.)

Stem cell video collection

Here's a video featuring Scotland's Dr. Colin McGuckin, who has been doing research on cord blood stem cells. Dr. McGuckin has worked with the University of Texas Medical Branch at Galveston and NASA to produce embryonic-like stem cells from umbilical cord blood cells. His lab has gone on to stimulate those embryonic-like stem cells - that no one had to die for - into functional liver cells, masses of liver cells and pancreatic cells that produce insulin and the other hormones vital to the regulation of diabetes.

The video is part of a collection on YouTube, by "Stem cells that work." Visit the YouTube page with great collection of videos about stem cells, including the excellent 50 minute "Google" video, "Everything you wanted to know about stem cells."

Skeptical view on Expelled, the Movie

Michael Shermer, the Skeptic, has seen the movie, Expelled, in advance of its release Friday, April 18th, and posted a review on his blog at Scientific American.

Shermer is a spin doctor who, while purporting to follow reason, is actually better understood by the title he often sports, "skeptic." His near-"single-issue" is atheism vs. religion, specifically Christianity and Christians. He says in one of his books that he joined the Church of Christ (the conservative, no instruments) to impress a girl and never felt the conversion that should have gone with his baptism, but that he tried to justify his choice. He even went so far as to attend Pepperdine University, which is owned and run by the Churches of Christ. Rather than throwing out the bad and keeping or developing a faith in Jesus as he understands the Bible, he set about to prove to the world that religion is just one of the "weird things" that people believe. He loves to debate questions like "Is Religion a Force for Good or Evil?"

Shermer doesn't tell us that the agency that investigated Richard Sternberg's case against the Smithsonian agreed that he had been the subject of discrimination and a behind-the-scenes coordinated move to get him out of the Smithsonian. The case was dropped because he didn't belong to a protected group and he simply had no standing to sue within that agency, since he was not an employee. He did, however lose his lab space - going from a private office to a shared space and the privileges of unlimited access and his own key that he had enjoyed up to that time.

Also, Shermer claims that Sternberg went against policy in the peer review of the article by acting as editor and choosing the reviewers himself. Sternberg tells his side of the story and answers the charges against him at his own website, here, and here.


There's more on the web, including this review from 2006 Dispatches from The Cultural Wars , which details - and is an example of - the political nature of academia, research and the theme of Expelled.

Both sides spin to make a point. But, Sternberg's case appears to be a classic example of academia's - or any closed group with limited power to make change in the open - whisper campaigns and peer pressure to "expel" any doubters, gad-flies on the edge of scientific "consensus." Ironically, I've read that the reason that people don't understand the mutation that brings about changes in the gametes of individuals and eventually species, is that we don't understand really large numbers. Ironically, Intelligent Design began with the discussion about the mathematics involved in the evolution of species.

Nature nurtures debate on namesake

Josh Carter, over at the Bioethics.com blog, comments on the editorial in the April 10th issue of Nature, (subscription only. Joe quoted some but let me know if you need the full text) which uses news of a transgendered (but not transexual) pregnant and bearded woman to ask the age-old question, what is "natural" and whether "natural" is better than "un-natural."

What do you want to bet that the author prefers "natural" fibers for his clothes and "organic," when it comes to groceries? We know that the editorial board has opinions on the good and bad, since the cover of the April 3 issue in front of me has the headline, "Carbon emissions: it's worse than you thought."

Even though the question couldn't have been asked quite this way in the past, Nature asks one of the oldest philosophical questions. Unfortunately, they ask in a juvenile manner. In fact, they beg the question by stating that the approved purpose is to "enhance the human condition."

(As I commented on the Bioethics.com blog) The “natural” uses of medicine and science seek to discover and use our discoveries to encourage, enhance, and/or return to optimal what Aristotle called the “telos,” the “what it is meant to be.” For instance, a splint reduces pain and holds the limb in physiological position as it heals. Hip replacements, glasses and hearing aids aren't normally intended to give you the ability to jump higher or stronger, see with the sight of an eagle or hear a pin drop in the next county -- they are used in an attempt to return your functioning to "normal."

The most active debates in science today are actually discussions about the “nature” of the thing we are studying or manipulating. Is global climate change causing the Earth to heat up more than is “natural,” is it man-made (due to those carbon emissions), or cyclical, etc. Should there be regulation on abortions to for sex-selection or to choose for deafness? Who gets the resources to be the Six MillionTrillion Dollar Woman and why not allow men and women to demand that their limbs be cut off or that their faces be botoxed and surgeried into a human caricature that scares children?

Again, we see the problem with setting up the ethics hierarchy so that "autonomy" trumps "non-maleficence." "I want" ethics over "First, do no harm."

Is there good in the telos, or is there any standard for dividing funding and power in science and medicine? If there aren’t good and bad uses of science and medicine, then “Anything goes,” if you can get the financing, the power, or the ability to do it.

What I've been doing instead of blogging

For those of you who might have noticed that LifeEthics took a bit of a slow down over the last couple of months - I have to admit that there's only so much time in the day. And so much adrenaline in my body.

For one thing, we've been involved in the Republican Primary. Our local incumbent State Representative lost to the new guy -- by 17 votes out of 30,000!

The really time consuming thing, though is that we've been living in an old house for the last 14 years. Over the last year, we've been developing plans for a pretty extensive remodel. After we came up with the perfect new floor plan, the city refused to give us a permit. It turns out that FEMA's new flood plain map "moved" our house from the 500 year plain to the 100 year plain - and the architect didn't notice.

The rules would have meant raising the house 2 feet. However, the house was concrete pier and beam -- and walls, floors, and ceilings. Concrete evidently doesn't handle being raised, very well.

So, we had to move, store most of our stuff, and tear down the old house - see the pictures of the demolition. And remember that this is the house that the city engineer claimed might float up and turn on its side.

Gynecology and Obstetrics Policy makers respond to doctors on conscience

It appears that the American College of Obstetricians and Gynecologists and ABOG (the American Board of Obstetricians and Gynecologistsmay be about to abort their efforts to change laws concerning conscientious refusal in Washington. It remains to be seen whether they will deliver on their promise to support -- without limits - the Conscientious Refusal to perform or refer for certain procedures. (I'm sorry, I can't resist obvious puns, even on such a serious subject.)

LifeEthics has been covering the controversy over the American College of Obstetrics and Gynecology's "Opinion #385, Limits of Conscientious Refusal in Reproductive Medicine," which states that,

Providers with moral or religious objection should either practice in proximity to individuals who do not share their view or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient's physical or mental health, providers have an obligation to provide medically indicated and requested care."

First, "medically indicated" should be up to the physician and not dependent on autonomy - the patient's wants and wishes. Remember that Joseph Kennedy, the father of John and Robert, had his daughter lobotomized because she was too wild. At that time, according to Joe, the lobotomy was medically indicated.)

Obviously, this is not a moral obligation - but one that can be enforced by the use of the words "standard practice" and "standard reproductive services." In other words, abort, refer, or face lawsuits and risk your board certification. And the definition of "emergency" varies.

We also reported that the Secretary of Health, Michael O. Leavitt, had written to the Presidents of the American College of Obstetrics and Gynecology, the professional organization that supposedly sets the standard for these professionals, and the American Board of Obstetrics and Gynecology which certifies and tests OB/Gyns Presidents of ACOG and ABOG. He informed them that they were in danger of risking their own funding for training programs and status by any attempt to override the protections for Conscience in Federal funding regulations.


Even NPR noticed and covered the controversy.

The leaders at the Christian Medical and Dental Association have let CMDA members know that the President of ACOG, Kenneth L. Noller, MD, responded to the Fellows (certified OB/Gyns) last week and Norman F. Gant, MD, the President of ABOG, responded to Secretary Leavitt by letter on March 19, 2008.

Dr. Gant doesn't have a clue what the Secretary is talking about:

I am responding to your letter addressed to me asking about the American Board of Obstetrics and Gynecology’s stand with respect or to a physician’s choice to violate their conscience by referring patients for abortions or taking other objectionable action, or risk losing their board certification.” I can only say that I do not know where you came up with any suggestion, much less documentation, that the American Board of Obstetrics and Gynecology has ever asked anyone to violate their own ethical or moral standards.

And Dr. Noller reassures the Fellows that in this case, an Opinion is just an Opinion (and we're supposed to forget the attempts to change the laws):

We want to be clear the Opinion does not compel any Fellow to perform any procedure he or she finds to be in conflict with his or her conscience and affirms the importance of conscience n shaping ethical professional conduct. For example, while this is not a document focused on abortion, ACOG recognizes that support of or opposition to abortion is a matter of profound moral conviction and ACOG respects the need and responsibility of its members to determine their individual position on this issue based on their personal values and beliefs. We want to assure members with a diversity of views on this issue that they have a place in our organization.
Ethics Committee Opinions provide guidance regarding ethical issues. This Committee Opinion is not part of the “Code of Professional Ethics of the American College of Obstetricians and Gynecologists.” This Committee Opinion was not intended to be used as a rule of ethical conduct which could be used to affect an individuals initial or continuing Fellowship in ACOG. Similarly, it is not cited in the American Board of Obstetrics and Gynecology’s “Bulletin for 2008,” and “Bulletin for 2008 Maintanence of Certification” and an obstetrician-gynecologist’s board certification is not determined or jeopardized by his or her adherence to this Opinion.
Conscience has an important role in the ethical practice of medicine. While this Opinion attempted to provide guidance for balancing the critical role of conscience with a woman’s right to access reproductive medicine, the Executive Committee has noted the uncertain and mixed interpretation of this Opinion. Thus, the Executive Committee has instructed the Committee on Ethics to hold a special meeting as soon as possible to reevaluate ACOG Committee Opinion #385.

Dr. Nurse? Why not just Doctor?

Get ready for Dr. Nurse, who will call himself/herself "Doctor," but who, after 4 year bachelor's degree in nursing, has gone to the Doctor of Nursing school for two years with a one year internship -- that's compared to the 4 years of college, 4 years of medical school, followed by at least 3 years of residency that Family Physicians, Pediatricians and Internal Medicine docs devote to training..

The Wall Street Journal reports (please let me know if you can't access this page) that the National Board of Medical Examiners will begin testing these "DrNP" candidates this fall.

From the Wall Street Journal:

As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

So,the supposed reasoning behind the new doctorate is this shortage of primary care doctors. That shortage has been artificially encouraged by all sorts of federal interventions. For some reason, no one's considered paying Family Doctors more!

Instead, there are schemes to divide and re-divide the Medicare "Pie." There are the rural health clinics, which are paid more by Medicare and Medicaid than your local family doctor, pediatrician or internal medicine doc for seeing the same patients. In order to qualify, the clinic -- get the distinction, there, not the doctor, but who ever it is that owns the clinic and contracts with doctors and hires the rest of the staff - must hire at least one "mid level practitioner" to see patients. They can't hire a doctor to do the same work and/or for the same money -- they must hire a Physician Assistant or Nurse Practitioner.

As the article notes, the main reason for the loss of primary care physicians, however, is the low pay for the thinking part of what we do, compared to the procedures of specialists, such as all the varieties of surgeons, urologists, gynecologists and gastroenterologists. We analyze, examine and determine treatment or treatment change, resulting in "Evaluation and Management" visits. Rather than the codes used for procedures, the E&M visits are divided into levels of payment based on a set of check lists and diagnoses. The money from Medicare - followed closely by the insurance companies - has consistently shifted from the office visits toward the procedures.

Needless to say, the smart medical students -- or at least the ones more interested in money than in your family history, living arrangements and whether Junior ate his peas and carrots will become interventional sub-specialists, not a Family Physician or Pediatrician.

A few years ago, Medicare payments increased for home health agencies, which encouraged RN's and LVN's to leave the hospital. Medicare quit paying your family doc to "scrub in" with the general surgeon or orthopedist as an assistant during your gall bladder surgery, colon resection or hip replacement. But, they did pay the surgeon enough to justify the hiring of a nurse practitioner or physician assistant. And studies said there was no difference or even better outcomes, since the "team" worked better in the Operating room and the peri-surgery procedure became more efficient.

(Of course, the NP or PA won't be available to your wife or kids for questions next week, and won't watch the effect of your new level of activity on your blood pressure or diabetes. And your family doctor may no longer even know that she should, since she won't even find out about the surgery until your next visit or hospitalization. But that has nothing to do with the outcome of the surgery, right?)

The increase of Federal funding for Nurse Practitioners has exacerbated the loss of good RN's and LVN's - leading to more of the Federal pie going to nursing schools. And the DrNP will probably have the same effect. The WSJ article mentions the lack of faculty in the nursing schools. The funding will have to come out of the Medicare and Federal "pie."

However, what patients need to consider is whether the DrNP training can truly accomplish the same training in 3 years that our Medical Schools can do in 5 to 7 years. Some have said that mid levels can handle 80% of what doctors do.

It's that 20% that is the difference between knowing what you don't know and planning for the 2 AM crisis.

Designated Donations (Saving black girls from punishment)

There's no way to avoid the politics if I'm going to comment on these two stories.

First, here's a link to the audio recordings of Planned Parenthood employees, agree will be earmarked to decrease the number of "African Americans" or a "black baby." The employees include the Vice President of Development of the New Mexico PP, Sue Riggs, agreeing to accept money that the caller has specifically said should go to the abortion of an African American. Another call includes the statement that the man does not want his children to face a lot of competition in college due to affirmative action.

These calls should be enough to make any thinking person condemn at least the lack of sensitivity and training at the offices of Planned Parenthood. Unless you realize that they probably think they're rescuing a black woman or girl from the punishment of having a black baby -- as stated so clearly by Barack Obama last Sunday, March 30, while campaigning in Philadelphia:

"I've got two daughters -- 9 years old and 6 years old," Obama said. "I am going to teach them first of all about values and morals. But if they make a mistake, I don't want them punished with a baby. ... So it doesn't make sense to not give them information."

The mindset that calls pregnancy a "punishment" is one that we who value human life often encounter. In a classic case of projection - seeing your own opinion, wants, flaws or tendencies in the other person - the abortion advocate will claim that we see sex as bad, and that women and girls should be punished.

No, we see women and girls as us. We see their babies as the children of the future - as our fellow human beings and citizens. The information that we give our children is that there are consequences to our actions. Each of us has a responsibility to work toward good consequences by choosing our actions. Taking responsibility, expressing compassion and empathy, and even parenthood are not "punishment."

In fact, you could call the opportunity and ability to do so a "blessing."

Edited 4/2/08 at 10:00 PM for typos.

Human-DNA-in-cow-egg embryo created in UK

Scientists in the UK report that they have created an embryo using the transfer of human nuclear DNA from an embryonic human cell into the oocyte of a cow that has had the nucleus removed. These embryos are the "hybrids" or "cybrids" that we've been discussing for the last few years.

From the Guardian:

Apparently these researchers have achieved some success - but by using the nucleus from a very early embryonic cell, which might be easier to reprogramme than an adult cell. At the moment it is impossible to assess the significance of this report until we know more details of what has been achieved ... the results have been repeated and, importantly, they have been reviewed by independent researchers in the usual way."

Josephine Quintavalle, of the pressure group Comment on Reproductive Ethics, said the research should not worry those opposed to hybrid embryos because the Newcastle work did not seem convincing. "The embryos didn't survive, they were created from embryonic stem cells rather than adult tissue, and there's a lot of question marks over the research."

But she added: "What it has done is wake up the public to this reality, that while parliament is getting in a tizz about this, while the whole country is up in arms discussing it, the HFEA is already issuing licences."

Supposedly, if the technique is perfected to allow the embryos to survive longer, these embryos will allow the study of the early embryo and production of embryonic stem cells in order to learn more about and find cures for diseases like diabetes and Parkinson's.

However, even if the embryos are disorganized and fail early, or if they are destroyed at day 5 or 6 or whenever, the ethical determination as to whether they are "human" or "bovine" has not been cleared up. We won't know what they are until several labs and several trials successfully create these embryos.

If the embryos appear to divide in an organized manner, producing human proteins and the differentiation necessary to create human embryonic stem cells, then they are essentially human embryos. This is a case of the old if it walks like a duck, quacks like a duck, etc., logic.

Since the stated intention is to destroy the embryo, and we don't know whether they are human or not, those of us who find the killing of humans, even at the earliest stages will also hold that it is inherently unethical to even begin the process.

A discussion about the discussions about the announcement can be read at one of Nature.com's blogs, "The Great Beyond."

From the thread, "UK hybrid embryo: in perspective - April 02, 2008,"

New Scientist has attacked the group for announcing the achievement through the media rather than through a scientific publication. The Independent focuses on the ethical debate. Not many organisations outside the UK gave it any coverage at all, and those that did may have been under the impression that it was a world first, not mentioning previous achievements in the field (eg. Life Scientist, Australia).