Some Dilemmas

There is a massive car crash outside the hospital. Five people are rushed in. It is immediately apparent that they all need transplants. Two of them need a kidney transplant; one needs a heart; another needs a lung; the last needs a liver. If they do not get the transplant, they will die. Meanwhile, another man walks through the door to get a routine check-up. The question is whether you can kill that man to harvest five separate organs and save the five involved in the car crash. Clearly, this is unethical, despite being utilitarian. There are many reasons; no one would go to the doctor if there was a remote chance that they'd be sacrificed for the greater good. But, in comparing this scenario to the trolley case, what's the fundamental difference?

Farfetched, perhaps, but consider another ethical question. Is withholding treatment any different than withdrawing treatment? Doctors are usually more comfortable with not starting a treatment in the first place (letting the disease kill the patient) rather than stopping treatment once it has started (yet, isn't the disease still killing the patient?) This is a question of omission versus commission.

Is there a difference between killing someone and letting them die? Of course, euthanasia is a hugely complex topic that spans philosophy to law to policy to medicine. Here, I just want to point out that we should not conflate cause of death with responsibility of death. The cause of someone's death is biological. Responsibility comes about if a person makes an ethically charged decision (or refrains from it). If I take a patient off of life support, I do not kill him. His underlying disease kills him. But I may be responsible, depending on the moral status of that action.

This is very important for physicians to understand. Not everything that happens is caused by human agency. Since human agency is necessary for moral responsibility, not everything that happens will hold someone morally responsible. For example, if you can't help but do something; that is, you have no free will with regards to something, then you can't be responsible for it. If, no matter what I do, a patient will die, then I am not morally responsible for the patient's dying. If I could have given the patient medication to save his life, then I do not cause his death, but I am morally responsible for it.

The Trolley Problem

The Trolley Problem is a classic philosophical thought experiment introduced in most ethical theory classes. I am not sure why it is a trolley, but in San Francisco and all, I suppose the story is appropriate.

A runaway trolley is racing down some tracks. You look ahead, and you see that if it continues on this track, it will run over five people. When this story is traditionally told, the storyteller often says these "five people were tied to the tracks by a mad philosopher." However, I assure you, the term mad philosopher is almost always an oxymoron (save in the case of Nietzsche; but I digress). You also see that there is a switch to move the trolley to another track. However, there is one person tied to this track.

If you let the trolley take its course, it will kill five. If you flip the switch, it will kill one. What is the ethically praiseworthy action (or the lesser of two evils) in this case? Most people (I would imagine) lean towards flipping the switch; the one person is a tragedy, but one is of course smaller than five.

Take this second scenario. A runaway trolley is racing down some tracks. A crowd of spectators has gathered on top of an overpass to see this trolley. Why? Because some mad philosopher tied five people down on the tracks and the trolley will run them over. But, you realize that the person in front of you (taking many pictures) is a really fat man. In fact, if you pushed him off the overpass and onto the tracks, you can effectively stop the trolley and save five people.

Now, wait. Most people (perhaps you) might have thought that killing one and saving five in the first scenario was permissible. But you might be repulsed at doing this in the second scenario. Strange. What exactly is the fundamental difference between the two situations? Is there a fundamental difference between the two situations? Here are some thoughts. You intend harm to the fat man whereas you don't intend harm to the single person. Or maybe you actively harm the fat man whereas you don't actively harm the single person. But what about utilitarianism? In both cases, five lives are greater than one. What if instead of five, it was fifty? Would you actively kill one person to save fifty? Fifty thousand? Or, what if instead of the fat man, it was your mother? How would that change things?

Death and Morality

Is death a moral evil? Here, I distinguish moral evil from other kinds of evil - perhaps religious evil or personal evil or societal evil; I'm not sure. Death may be bad because of a lot of things. (And, on the other hand, it may not be bad at all - at some point, I will push that argument). But a moral evil entails some sort of moral responsibility. A morally blameworthy action is that because a free agent chooses to take that evil action. Excluding things like murder, is death a moral evil?

Well, first let us suppose that death is evil. Then, it would be a moral evil if its "evilness" is contingent upon the actions of a free agent. This is just philosophical rambling, but let me see if I can clarify. A meteor hitting the earth causing the extinction of dinosaurs may be evil, but that occurrence is not morally evil because no human caused it to be. (Here, I confound human with free agent, but most ethics deal with human actions, and it would be somewhat far fetched to suppose a free agent alien aimed to destroy dinosaurs).

At first glance, death doesn't seem to be a moral evil. After all (excepting some circumstances), we don't intend for another person to die, much less cause it to come about. But with the advent of modern medicine, death encroaches upon this realm of moral evil. After all, in some cases, medicine can stay death's hand. Suddenly, it is within the power of a free agent - the doctor - to give or withhold medicine. We have some limited control over death, it may seem. Does it then become a moral issue?

This seems to be the case. Most would agree that, in general, doctors are morally obligated to preserve life. To do otherwise would be to commit a moral evil. Even though death may be inevitable, doctors may be charged with the moral responsibility of using all of medicine's resources to delay this inevitable evil. Are we, then, fighting a losing battle? Are we never to accept death? Are we to sacrifice everything in order to prolong life, since life is good and death is bad? Is a doctor's obligation solely moral, and if so, what does that mean? With modern medicine, our fundamental attitudes towards death have greatly changed.

Desensitization

I remember less than 6 months ago when we first began anatomy, I was filled with apprehension. I was hesitant to touch anything, much less cut or probe or retract. The cadaver seemed so fragile, so human, sometimes scary, sometimes disgusting. I wasn't sure what I was allowed to do or what I wanted to do. I played the role of observer while my peers delved into the internal organs and tissues and vessels of this dead body.

Much of that has changed. While I might not be eager to excise an organ or tease away a nerve embedded in a muscle, such things are intellectually fascinating. I like doing them, though I recognize that someone is being dissected for my education. I no longer feel disgust or fear. I have a sense of awe of the human body and its complexity. On the one hand, I worry that I am becoming desensitized to anatomy, but on the other hand, I feel that I have progressed in my medical training. The transformation of the medical student over time is both mysterious and inevitable.

"Purposes of Medicine"

This 1965 Lancet article by Sir Theodore Fox has lots of great quotes, and so this entry will be a continuation of the last one.

"What a patient needs first is care and relief. In the second place he wants restoration to health [...] Since preserving his life is a sine qua non of restoring him to health, it is an end that those who have the care of him pursue, and ought to pursue, as a general rule. But it is not in itself an ultimate."
"If [a doctor] goes on prolonging a life that can never again have purpose or meaning, his kindness becomes a cruelty [...] We shall have to learn to refrain from doing things merely because we know how to do them. In particular we must have courage to refrain from buying patients' lives at a price they and their friends do not want to pay."
"The physician is not the servant of science, or of the race, or even of life. He is the individual servant of his individual patients, basing his decisions always on their individual interest."
"Our purpose is to enlarge human freedom - to set people free, so far as we can, from the disability and suffering that so easily mar their lives and hamper their fulfillment."
"With all its faults the profession to which [the doctor] belongs is not a body of technologists interested solely in the means by which physical or mental processes can be restored to normal: it is a body of doctors seeking to use these means to an end - to help patients cope with their lives."
"For a person or a profession, to restore and help one's neighbor may be no small task. But the purpose is not a small one; nor is the privilege."

100

This happens to be the 100th post in this blog. I'm not sure if this is an occasion for celebration, but perhaps some reflection on the past is in order. In October 1965, The Lancet published an article titled "Purposes of Medicine" by Sir Theodore Fox. Here are some good excerpts.

"In 1656 William Harvey bade us search and study out the secrets of Nature by way of experiment."
The medical profession and the church "are anomalous in being allowed to put service to mankind before service to the national group from which they spring [...] Even in war, [the doctor] may be permitted to believe in human brotherhood - to treat all men without political or racial or religious distinction."
"Our profession cannot regard anybody's life as expendable, nor anybody's life as forfeit. For no human being can be excommunicated from the human race. [Yet] I dissent utterly from the view that a negative decision not to prolong a life is the same as a positive decision to shorten it."
"Not least do people differ in their attitude to life. Some cling to it as a miser to his money, and to as little purpose. Others wear it lightly - ready to risk it for a cause, a hope, a song, the wind on their face. When so many people think of it as a means, the doctor, surely, would be wrong to insist that it is always the first of ends. Life is not really the most important thing in life."

Brinksmanship

British philosopher Bertrand Russell compared nuclear brinksmanship of the Cold War to a game of chicken. This analogy has been carried over to medicine. In the case of medicine, we want to treat a dying patient as aggressively as possible before crossing that line at which medical intervention does more harm to the patient than good. We aren't particularly good at this. There is no clear demarcation between life and death, as evidenced by the Terri Schiavo case. When should we let nature take its course? When should we put the patient at risk in an attempt to stave off the inevitable? There is great uncertainty in death. In Western Attitudes, Philippe Aries says, "Death has been dissected, cut to bits by a series of little steps, which finally made it impossible to know which step was the real death." Coma, dementia, vegetative state? Where do we draw the line?

And what kind of death do we want? Probably one in which we are embraced by people, not medical machines. In Daniel Callahan's The Troubled Dream of Life, he says, "There is a need to fashion a notion of the self that has, in some sustaining way, come to accept death, a self that understands that control over fate will pass from its hands [...] It should also be a death marked by consciousness, by a self-awareness that one is dying, that the end has come - but, even more pointedly, a death marked by self-possession, by a sense that one is ending one's days awake, alert, and physically independent." The difficulty for doctors is that we, in our combat against death, fail at brinksmanshipping. We overplay our cards for personal, societal, moral, or other reasons. This may contribute to a worse outcome for the dying.

Sailing to Byzantium

I
That is no country for old men. The young
In one another's arms, birds in the trees--
Those dying generations -- at their song,
The salmon-falls, the mackerel-crowded seas,
Fish, flesh, or fowl, commend all summer long
Whatever is begotten, born, and dies.
Caught in that sensual music all neglect
Monuments of unageing intellect.

II
An aged man is but a paltry thing,
A tattered coat upon a stick, unless
Soul clap its hands and sing, and louder sing
For every tatter in its mortal dress,
Nor is there singing school but studying
Monuments of its own magnificence;
And therefore I have sailed the seas and come
To the holy city of Byzantium.
-Excerpted from "Sailing to Byzantium" by W.B. Yeats

Death is a fascinating topic to me, from both philosophical and medical standpoints. How are we to approach death? What kind of attitude should we have towards it? Are we to be resigned? Scared? Welcoming?

In the past, before medical interventions could extend and prolong life, death was an accepted phenomenon. The diseases that killed, mostly infectious diseases, were fast; though there was suffering, it was not prolonged. Death was tolerable and familiar; one submitted to it. On the other hand, death now is highly uncertain; medical intervention can slow its progression and lengthen its tenure. The causes of death today - cancer, heart disease, stroke - are crippling over an extended period of time. We're afraid that medicine doesn't know its bounds or when to stop, that doctors will keep piling catheters and lines and drugs on top of each other even after the patient has crossed the threshold. In the intensive care units, the operating rooms, the emergency room, community is replaced by metal and steel and tubes and needles. With great technological advances, we have zoomed so far into this discrete endpoint of death that it is now a fuzzy blur, and we cannot say when it starts or ends.

One question of history I have is whether death is better today than it was in the past. I think that there is no doubt life is better today than in the past. People who would have been crippled by polio, incapacitated by accidents, dead at giving childbirth, now live full and rich lives. Our health is better, our lives are longer. But is the experience of death any better? That's a hard question. Certainly, pain medications provide great palliation in the face of such adversity. But I'm not so sure medicine has tamed death at all. We struggle to understand it, to define it, to come to terms with it. For all we know about the biological processes of life, we know very little about death and how to deal with it.

Puzzler

A woman, while at the funeral of her own mother, met a guy whom she did not know. Despite being total strangers, she thought he was amazing. She believed he was her dream guy so much that she fell in love with him right there, but never asked for his number. After the funeral, she realized she had no way of locating him. A few days later, she kills her sister.

What was her motive for killing her sister?

(Answer is below in white text - highlight to show).

She was hoping the guy would appear at the funeral again.

Interestingly, this question may reflect the thought process of a psychopath. When given to many arrested serial killers, they were more likely to figure the answer out.

Orphan Diseases

Orphan Diseases are extremely rare, with a prevalence of less than 5 per 10,000 (fewer than 200,000 in the U.S.). Fibrodysplasia Ossificans Progressiva is an orphan disease. The problem with orphan diseases is that few people do research on these diseases. The rarity not only makes the process of research difficult, but it also makes funding scarce. In particular, it is not cost effective for drug companies to develop medications to treat diseases with very low prevalence; from a business standpoint, there's no demand. However, the Orphan Drug Act of 1983 aids these companies to develop drugs for these patients by giving them longer patent rights, tax benefits, etc. In fact, drugs for multiple myeloma, cystic fibrosis, and snake venom came out of this Orphan Drug Act.

In any case, there is an ethical question: how much resources should be spent on low prevalence diseases? If the goal of research is to maximize health benefits for the most number of people (a highly utilitarian approach), then it seems that few resources should be allocated to orphan diseases. After all, 2500 people in the world have fibrodysplasia ossificans progressiva. Yet "some 7,200,000 men and 6,000,000 women are living with some form of coronary artery disease" (Wikipedia). If you take a completely objective, utilitarian approach - which might seem the most "scientific" - how do you justify spending any resources on FOP? But if no one researches FOP, then those patients are doomed to a disease which we won't do anything about.

I find these ethical dilemmas particularly interesting, but they are not by any means novel. Philosophical ethical theory has focused for centuries on this tension between utilitarianism and Kantian ethics, but developing practical guidelines from first principles is always a difficult endeavor.

xkcd

(xkcd, "a webcomic of romance, sarcasm, math, and language" is created by a former NASA roboticist Randall Munroe. Most of it's funniest comics deal with computer science and math, but I was very amused by this one. It is licensed under Creative Commons Attribution-NonCommercial 2.5 License.)

Advert

I know I generally don't blog about topics unrelated to medicine or medical school, but I wanted to post something about one of my extracurricular activities, a Stanford performing dance group. Every year, Stanford students organize a Viennese Ball, modeled after European waltz balls. This year, I joined the Opening Committee which performs a Strauss waltz and polka at the very beginning of the ball. It's been a whole lot of fun; I love social dance, and it's a good break from medical school.

The 30th Annual Stanford Viennese Ball is this Friday, 16 February 2007 at the Hyatt Regency in Burlingame from 8pm to 2am. I guarantee the Opening Ceremony will be worth attending; our choreographies this year are entertaining, elegant, and exciting. There's even a stochastic dancing section (as I like to call it). There will be two live bands, two dance floors, waltz, swing, salsa, polka, and other social dances. Of course, many Stanford dance groups will perform. I highly encourage anyone interested in social dance to check it out. I believe tickets will be sold at the door.

This is a picture of all 38 of us in our tuxes and dresses in the Main Quad at Stanford. I usually don't post pictures of people since I'm not sure whether people want their pictures posted, but I think it is fine in this case.

The Medusa's Gaze

Fibrodysplasia Ossificans Progressiva is a rare genetic disease in which fibrous tissues like muscle spontaneously and irreversibly turn into bone. It's scary. This ossification can affect joints and paralyze the patient. Patients usually lose all mobility by 30 and die by 40 due to paralysis of the diaphragm. Furthermore, this condition is induced by trauma, so surgery to remove ectopic bone causes further bone formation to occur. There is no treatment for Fibrodysplasia Ossificans Progressiva.

I heard a talk by Dr. Kaplan of UPenn who has studied this disease intensively and identified the gene that causes it. He is an inspirational person. Originally a purely clinical orthopedic surgeon, he was so struck by this disease that he dedicated his life to the patients that suffer from it. Over 15 years, he has meticulously investigated patients with this rare genetic defect. From his speech, I realized he is incredibly passionate about his patients even though nothing can be done for them.

His research is a pretty amazing story. His scientific and clinical acumen become very apparent when you think about the difficulty in tackling a disease that happens in one in a million people. Furthermore, most patients with this disease cannot have children, which makes traditional genetic and genomic techniques incredibly difficult.

The disease itself is crippling. Most doctors are unfamiliar with its presentation: short big toes and the overnight growth of tumor-looking bumps on the back, shoulder, and neck. Most doctors will assume this is cancer and biopsy it; this trauma can induce progression of bone formation. I read a paper that looked at iatrogenic (doctor-caused) harm to these patients due to lack of awareness of the disease. The paper also showed that few textbooks (other than those on metabolic bone disease) actually described this disease in adequate detail.

I am glad to have heard this talk by the world's leading researcher and supporter of patients with this extraordinarily rare, debilitating disease.

Calyx

One of the renal pathology professors has two cats named after kidney-related anatomic parts: Calyx and Henle. I actually really like those names; they're fascinating, unique, and fun. Upon hearing this, my high school friend Revati said, "Wait, isn't a calyx a group of sepals?" Sepals are a part of a flower beneath the petals. Well, in fact, a calyx is not only a part of the kidney, but also a group of sepals. I argued that the professor probably named her cat after renal anatomy rather than flowers, but Revati disagreed.

This is her story of how the professor's cat came to be named Calyx. "Perhaps the professor was wandering the countryside of England one day when she ran into a stray botanist. They spent one day together in perfect harmony. He explained flower parts, and she explained concentration gradients. And each remembered one term in common. Your professor named her cat Calyx to remember the botanist. But somewhere out there, there is another pet with the same name, this one in honor of the kidney." Revati is indeed the soul of wit.

Hyper and Tense

Hypertension is really an insidious disease. Tiny changes in blood pressure (even just 5 mmHg) can have a substantial effect on mortality and morbidity. That surprised me. I'm not even sure my precision with the blood pressure cuff has error bars that small. Furthermore, there are few symptoms related to high blood pressure. Without warning, the patient may be at risk for strokes, heart attacks, cardiomyopathy, retinopathy, and nephropathy. It's scary. Furthermore, it's hard for people to take medication since there are no symptoms of hypertension. You feel worse when you take medication because of the side effects. Thus, fighting hypertension is a tough battle.

In other news, we had a case in Foundations of Patient Care that spanned three weeks. On the first week, we interviewed a standardized patient at the clinical skills center. After taking note of his symptoms and history, we began to form a differential diagnosis. The next week, we followed his case closely, and unfortunately, a perceived pneumonia turned out to be a lot more severe. The last week, we wrapped up the case and also met the standardized patient again to practice a motivational interview to encourage him to stop smoking. All in all, the case was fascinating. I really enjoy exercises like this.

On a related note, today we had a "communication skills midterm" with a standardized patient. We took a medical history, paying particular attention to building rapport, eliciting information, and respecting the patient. Then we had to come up with a differential diagnosis for the symptoms, which I found very difficult. That's definitely something I need to work on from now until my third year.

Kid me not

Heartily tired of cardiovascular and after blowing through pulmonary, we finally arrive at the renal portion of this block. The kidneys are interesting. Ask any kid what his heart or lungs do, and he's likely to know. But I don't think I knew what the kidneys did when I was in elementary school. Yet they are incredibly important and fundamental organs, regulating half a dozen bodily processes like electrolyte and fluid balance.

In any case, this block has been tough. The kidneys are complicated organs, with ions and channels and acid-base calculations. There's a lot of physiology. We started off learning about glomerular diseases, incredibly rare entities like lupus glomerulonephritis and Goodpasteur's syndrome. I thought this was a little odd since we have not yet covered diabetes, one of the most common causes of kidney disease. But I guess it's important to learn about the histology and pathology of the kidneys. This seems to be an essential part of nephrology; we spent hours trying to read light microscope, immunofluorescence, and electron microscope scans of glomeruli. I actually really enjoyed one of the path labs in which we got histories of unknown cases and images of renal biopsy and had to diagnose the patient. That was pretty cool.

Fire Alarm

Last Friday, during small group, a fire alarm went off. After we shuffled out of the building, some of my exceptionally academically-oriented peers decided that we should continue going through the problem set at someone's apartment. Crazy.

Take My O2 Away

On Saturday, January 17, we had a "Medical School Formal" with the theme "Take My O2 Away." I'm not really sure what to think of the concept of a med school prom (as many of us called it), but it was fun. It took place at the Hyatt at Fisherman's Wharf, a really nice venue. I was impressed. There was a lounging area with elegant fountains, fireplaces, and comfortable couches as well as the dance room itself.


In any case, I had dinner at a really cozy French cafe down at Palo Alto with my girlfriend Kate. We then came back up to the city to get ready before heading downtown. Although arriving fashionably late at 10, I found out that the dance didn't really get started until 9:30 or so. It was fun seeing everyone all spiffed up and outside the context of 8am small groups. I really enjoyed that. Although we were only there for a couple hours, it was a really nice evening.

Stan Glantz

I heard a lunchtime talk by Stan Glantz, an incredible anti-tobacco researcher and policy-maker. Back in the 1970s, he became very interested in tobacco company tactics to sell cigarettes and ways to combat them. At the time, it was already known that smoking was bad for the smoker. However, this had very little effect on smoking. It soon became clear that the controversy over smoking would be fought over its effects on other people. In fact, the tobacco companies knew that if smoking was shown to be harmful for spouses, children, roommates, etc., the economic consequences would be devastating. That's an interesting concept, but one that makes a lot of sense. Many people believe they have the right to harm themselves, but few people would assert the right to harm others.

In any case, the tobacco companies decided to fight the tobacco wars over the restaurant industry. They tried to make the case that restaurants who decided to have separate smoking and non-smoking sections would lose an unbelievable amount of money (30%). This ploy was fairly successful, but Stan Glantz found it suspicious. He finally used the case study of Beverley Hills, which went non-smoking for a short period of time, to show that restaurants did not suffer at all. Thus, he single-handedly began a fight against the all-powerful tobacco companies. Later, he conducted studies to prove that second hand smoke causes a tremendous increase in heart attack admissions to the ER. From an against-all-odds position, he snowballed into the opposition against the tobacco industry today.

Most of all, his presentation was awesome. He was an excellent storyteller, throwing in humor, vignettes, and science into this beautifully educational yet immensely entertaining tale of the last three decades. I highly suggest going to his talks; they're completely worth it.

Poignant

Today's lecture discussed the collecting duct in the kidneys. One of the important channels here is the aquaporin. Last year, I met one of the people who discovered the aquaporin, Dr. Peter Agre. He (along with Roderick MacKinnon) won the 2003 Nobel Prize in Chemistry for this discovery. On a side note, I remember him telling me he got a D in his first chemistry class. How things change. He is currently the director of the Medical Scientist Training Program at Duke University.

When I went to Duke for MSTP revisit, I met Dr. Agre. His warm, humble, and welcoming personality really attracted me to Duke's program. He seems like an excellent mentor. In any case, the lecture today on aquaporins reminded me of that experience. I chatted with the Nobel Prize winner who discovered these molecules, now familiar to every biology and medical student. I think about my discussions with him, which had to do with where I was from, what I was interested in, what I thought of the South. I think about his presentation on how he discovered aquaporins (completely serendipitous). I think about the time he called my cell phone while I was paying for dinner at Subway. One of the hardest things I've had to do was to decline Duke MSTP to come to UCSF.

It's weird. I don't wish I was at Duke, but perhaps there is some slight measure of regret, exacerbated by this encounter with a molecule that was first identified by a guy I met and liked.
I am again inspired to do research for searching's sake. There are so many amazing, brilliant, and inspiring people around me.