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Notebook Medicine




More equal than others?

When society decides killing is a ‘cure’

When I called to discuss my bill for a few lab tests for my medical practice, the on-hold recording included an advertisement for a “noninvasive prenatal screen.” The lab company’s website elaborated that the “timely information about your fetus’ chromosomal makeup ... can help you make decisions with your healthcare provider.”

What sort of decisions would those be?

In his landmark 1986 work The Nazi Doctors, Robert Jay Lifton explored how the dog-bites-man story of tyrants murdering citizens turned into the man-bites-dog story of doctors being the ones who killed. He summarizes at the outset: “Prior to Auschwitz and the other death camps, the Nazis established a policy of direct medical killing: that is, killing arranged within medical channels, by means of medical decisions, and carried out by doctors and their assistants.” Even as the murder moved to the Holocaust’s industrial scale, doctors researched, designed, and supervised the systems that performed it.

Lifton traces that sordid history to “mercy” killing, then to the notion that people deemed defective were subhuman; he quotes Alfred Hoche, a professor of psychiatry from the University of Freiburg, stating in 1920 that killing them “is not to be equated with other types of killing … but [is] an allowable, useful act.” His reasoning focused on “the tremendous economic burden such people cause society to bear; especially those who are young, mentally deficient, and otherwise healthy.” The list of those deemed “life unworthy of life” soon grew to entire races—but the idea that physicians weren’t killing as much as curing, at least at a national level, remained.

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(Buero Monaco/Getty) ()


Physicians in white

What happens when old doctors’ skills fade, fade away?

A new law will allow Japan’s Emperor Akihito, who would otherwise have had to serve for life, to abdicate; he plans to step down in 2019 at the age of 85. This extreme approach to tenure contrasts with America’s federal judges: Firing one would take a (literal) act of Congress, but they’re free to leave whenever they choose.

Some lines of work take the opposite approach, setting a mandatory retirement age. Commercial pilots have to retire at 65—it had been 60, until a 2007 law added five years—and air traffic controllers normally retire at 56. In the Old Testament, the Levites had to step down from Tabernacle service at 50.

Where do doctors fit in? Pioneering heart surgeon Michael DeBakey practiced until his death at 99, and one of my own mentors practiced into his late 70s and stopped only because his mobility was failing him: He could no longer respond quickly to emergencies, but his memory and intelligence remained intact.

This isn’t always the case, and a 2012 Washington Post article on the subject quoted geriatrician William Norcross as estimating that 8,000 practicing doctors suffered from dementia. Concerns of that sort have given rise to a controversial idea called MOC, or Maintenance of Certification. Under MOC, medical board certification has moved from a once-for-life pair of exams to an increasingly complicated series of steps that repeats every 10 years. MOC proponents say the program ensures doctors keep their knowledge current. Detractors call it an expensive distraction from clinical practice.

Some hospitals and practices now require doctors to have MOCs, but critics ask: Who sets the topics that should be examined? Who chooses the right answers where there is disagreement? How often should doctors face these checks? What allowance should they receive for focusing on specific areas of practice—areas that may be only a small portion of a modern MOC exam? Will MOCs allow politicized credentialing bodies to insist on conformity with their agendas?

Many state departments of motor vehicles have started to require eye exams as drivers age, and some have introduced a system where people can report potentially impaired older drivers for a closer check. It’s not every day that I think DMVs do a better job than my own credentialing body, but their system works better than MOC. Like drivers, physicians often respond to their advancing years by setting limits for themselves: Where an elderly driver might avoid the roads at night or in inclement weather, older doctors often stop taking night calls, limit their practices, and gradually restrict how many patients they see in a day. MOC doesn’t account for those adaptations.

Some medical authorities now follow DMV practice. The University of California, San Diego, offers an Aging Physician Assessment, and Baltimore’s Sinai Hospital has a similar program focusing on surgeons. Both are voluntary, but Stanford went even further in 2013, requiring all doctors over 75 to undergo biennial evaluations. In each case, the programs focused on mental and physical health—as opposed to test scores and quizzes about guidelines.

The Stanford policy met with considerable debate about whether it constituted age discrimination, but even a rebuke from the faculty senate failed to stop it. It makes sense, and I agree with its emphasis on health instead of attitudes: I don’t want my doctor’s decisions to be micromanaged, but evaluating whether his skills are still equal to his job description seems fair. Dr. DeBakey commented—at 91—that he would not mind being operated on by a 91-year-old surgeon. If the surgeon were as skilled and robust as he was at 91, I’d agree.

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(Krieg Barrie) ()


Complicit in killing

Let’s encourage pharmaceutical companies to cut off the flow of abortion drugs

Florida recently performed the first U.S. execution involving an anesthetic called etomidate. The execution prompted a rebuke from the company that invented the drug: Janssen Pharmaceuticals (now part of Johnson and Johnson) is not currently among the drug’s eight producers, but stated, “We do not support the use of our medicines for indications that have not been approved by regulatory authorities.”

The company’s objection can’t be simply that execution is an off-label use for the drug, since off-label prescriptions (using a drug for reasons not officially sanctioned by the Food and Drug Administration) are common. A 2008 Stanford study found that doctors often prescribe Janssen’s anemia drug Procrit for off-label uses. Almost 10 years later, those uses remain popular, though they are still officially unapproved.

The anti-death-penalty group Reprieve collects on its website comments from drug companies, each expressing shock and horror that products conceived for healing are instead used for harm. The companies say they will refuse service to any customer or reseller linked to executions: Reprieve stated that with Pfizer’s 2016 decision to prohibit use of its drugs in executions, “all FDA-approved manufacturers of all potential execution drugs … have blocked their sale for use in executions.” While I find some of Reprieve’s commentary silly from a medical standpoint—yes, certain anesthetics hurt briefly during injection; no, that doesn’t mean I’m torturing my patients by giving them anesthesia—its argument that drug companies should refuse to participate in killing intrigues me.

But, following that logic, why stop with executions?

Neither surgical abortions nor medical (pill-based) abortions take place without the help of drugs. Our pharmaceutical industry has now decided that condemned felons merit protection from its products. It claims it will not stop at verbal complaints but will even go to court, as McKesson Corp. did in April in an attempt to stop executions in Arkansas. So, let’s encourage the drug industry to stop the killing—by refusing service to any facility that performs abortions.

Since drugmakers have decided to ban sales of their products for a particular legal purpose … they can no longer claim neutrality.

Drug companies that object to such an abortion boycott cannot complain they’re the equivalent of “common carriers”—a term the technology world uses to describe a neutral party that transports data or products without making ethical judgments about them. (The Postal Service is a good example of a common carrier, as are phone companies.) Since drugmakers have decided to ban sales of their products for a particular legal purpose—execution—simply because they disapprove of it, they can no longer claim neutrality.

Hospitals would surely complain that a no-abortions policy would interfere with legitimate uses of the drugs in question, since drugs used for abortions are also used in nonabortive medical procedures. But we can take the same position as the European Union, which bans exports of any drug found to be used for lethal injection: The end user must guarantee that the drug will not be used for killing. (This EU ban explains why the United States no longer has a source of the anesthetic sodium thiopental, which previously came from Italy and was used in U.S. executions.)

If a given hospital wanted to re-establish the flow of medication, it could do so simply by stopping abortions. Then the drugs would be available for the kind of medical care that heals instead of kills.

Idealistic? Absolutely. But surely Reprieve itself would have thought its own position to be equally idealistic only a few years ago. I never would have imagined a day when a drug company would sue to control how its products are used. That day is now here.

McKesson and Janssen declined to comment for this article.

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