Insulin and Eugenics... I am upset. This is a rant.

As a type 1 diabetic, I am often very angry. Usually this is secondary to hypoglycemia or an ability to eat something because I inadvertently left my insulin at home.

But today I am upset because I am running out of insulin and I only have $600 left in student loans until late February. Why is this a problem? Because as someone with good medical insurance, my doctors have always prescribed me humalog and lantus, which are bloody expensive without a prescription (and are actually still really expensive with a prescription and insurance: $50 each for what I need in a month). But as a medical student I don't have time to go see a doctor to get a prescription to get my bloody f***ing insulin. I am really upset because as I speak I have about enough humalog (lispro, short-acting insulin) to get me through to Monday, after which I guess I'll start employing a poor man's metformin: large amounts of acetaminophen and straight hard liquor. Your liver transaminases skyrocket, but you've effectively bludgeoned your body's best organ so badly that it stops going through with gluconeogenesis. Oh, and a ton of aerobic exercise makes your body more sensitive to the effects of lantus (glargine, long-acting insulin), so I guess I can look forward to dropping a few pant sizes and... cirrhosis. Lots of preventable, freaking cirrhosis.

I don't know what I'm supposed to do. There must be type 1's who are busier than me and have less time to see doctors. And I know there are type 1's who don't have health insurance because this country is absolutely terrible. So how can I get insulin at a reasonable price without having to see a doctor? Because, honestly, I've had diabetes for over ten years and I know my body's personalized ways of dealing with this disease in a way that literally no other health professional could understand. I know the tricks. I know the secrets of my metabolism. My A1c is always under 7.0 and my hypoglycemic events are now well controlled. I know what I'm doing.

SIDENOTE... no wait, MAIN POINT: I think it is absolute bullshit that people need prescriptions for something that their body erroneously stopped producing. Almost everyone else around me is making insulin, but just because my body f***ed up when I was thirteen, I have to spend thousands of dollars on a month's worth of high quality insulin? What kind of justice is that? Answer: it's not. It's wrong. It's condemning people to a constant economical disadvantage on top of the disease they've contracted who's co-morbidities will likely kill them if they don't control the aforementioned disease. In a country where medications aren't regulated to make them fairly priced (hell, I think they should be bloody f***ing free but I realize I'm incredibly biased) and health insurance is severely limited, we are essentially killing off diabetics. I realize that many type 1 diabetics can make it to reproductive age without dying first, but I've seen a 24 year old diabetic with f***ing gastroparesis--that's really severe neuropathy. And now that I've gone through OB-GYN, it becomes apparent that type 1 diabetics with A1c's of 13.6, like this 24 year old, would never be able to carry a healthy child to term. She will likely never produce any children because why? Because our health system is unjust? What sick kind of world is this?

And you know what's worse? The type 1 diabetic population that is under insured and hurting the most is minorities, specifically blacks. And you know what's f***ing insane about that? DIABETES IN AFRICAN POPULATIONS HAS NO DISCERNABLE GENETIC COMPONENT. Whereas caucasian type 1 diabetics usually have some weird HLA inherited predisposition sh*t. And yet, at least in Chicago, those people will be preferentially allowed to live with a disease that could be greatly reduced within the human population if only they were put to the slow and painful death that awaits most uninsured type 1 diabetics.



[edit]: Okay. So I calmed down a little bit. Let me just say that I recognize that a lot of white people don't have health insurance either. But at least in Chicago, economics and race are obnoxiously linked in a way that has already started to upset my psyche. So I'm sorry about that. The truth is, all type 1 diabetics are in an equally unfortunate place in a society where close health maintenance is ludicrously expensive.

And also, I don't think I do a good job of separating my emotion's from the job. Especially other type 1 diabetics so far along. Seeing another black, 24-year-old, type 1 diabetic, laying on a bed in the emergency department, clutching at her stomach and moaning for morphine, secondary to gastroparesis and then her resultant addiction to painkillers, really upset me I guess. I want to help them but I know that it's literally too late because you don't recover from severe autonomic neuropathy. You just suffer until you die. From something completely preventable.

I guess this whole thing bothers me, not just because on the whole diabetics are treated very poorly, but because I'm now a healthcare professional, and I am surrounded by physicians every day, but I don't think I can just ask them to write me a prescription for insulin because I'd rather go to work than call the doctor's office to set up an appointment, then call the dean of student affairs (another physician), and then the clerkship director (also a physician), and then drive to god knows where for a fifteen minute conversation with the doctor to write me a prescription so I can save $350 for something that almost everyone in the world doesn't think about.

It's upsetting. If I had my way, everyone with a type of medical/biochemical deficiency would be able to get whatever they need for next to nothing because that's what equality is. Hypothyroid? You get thyroxine, no problem. Chronically depressed? We'll get you an SSRI or maybe even some SNRI's if you're lucky and need more norepinephrine. Diabetic? We'll get you all the insulin you want. Because giving you anything less than that is a crime.




So this is where I read that Diabetes in blacks and asians is often idiopathic: http://www.aafp.org/afp/1998/1015/p1355.html
Although since I am both caucasian and african, I won't know if I have the idiopathic form until either A) my entire genome gets sequenced (I hear it's only $1000 now!) or B) they look for islet cell antibodies in my serum.

Hassling with the "Need" to Medicate Mental Conditions

I think I'd be a great psychiatrist:

1. I like sitting.

2. Physical exams are my worst competency in clinicals.

3. I have several mental conditions (possibly), but I most definitely have one.

4. I treat people with mental conditions like people.

5. I see people with mental conditions as people.

Now let me elaborate:

In clinical neuroscience we end up watching a lot of patient interviews. One day we saw one with a schizophrenic. Later, me and a group of people got into a discussion, and I was the only one on my side of the argument, which was basically, the person seemed fine and functional enough, and why should we deem him “flawed”?

Yes, he had once been an irritable and a frequent assaulter. But on medication, he seemed talkative—enough, he had moods—enough of them, and he seemed normal—enough.

[One small point, shouldn’t normal be set by the patient? For example, when I was depressed, I knew I didn’t want to be depressed, and I considered the feeling abnormal and I wanted it corrected. But if I have occasional hallucinations that I enjoy, why change that? Or if I have synesthesia? That’s enjoyable. Right? And like, all famous actors have dyslexia. And they talk openly about it and it seems normal now, although you could easily argue it’s not.]

No one agreed with me. "Here," they said, "is a deeply troubled man. He assaulted over 100 patients, nurses, and doctors at his first hospital—etcetera etcetera. He was barely lucid. He wasn’t making sense. He wasn’t talkative."

But these things seemed normal to me. The great variance of human personalities also includes medically treated schizophrenics.

And why are we so eager to eliminate imperfections? Even the term imperfections makes it sound like there’s a one true normal (there isn’t) or that there’s only so many ways a person can be functional (there aren’t). I don’t want to sound like the preachy 2^nd grade teacher you were scared of because they loved diversity thiiiiiiiiiiiiiiiiiiis much, but in all honesty, I hate the idea that mental illness has to always be treated and that we all automatically look down on people with mental illness because society has trained us to fear the abnormal, especially the mentally so. I’m not just saying this because I have a mental illness, but as a person who has known, talked to, interacted with, and dated people with mental illnesses, I say we should all work on the way we see others with DSM-logged disorders.

If you’re born with something, you shouldn’t have to awkwardly try to hide it constantly. And while most mental illnesses aren’t entirely genetic, many of them have a strong genetic component. Even more importantly, if you don’t want to hide it, you shouldn’t be forced to.

Schizophrenia an interesting mental illness. While I haven’t yet studied the topic enough to know if most schizophrenics are violent, I do know that public perception of schizophrenics paints them as violent.

[Side note: There was a great episode of Law & Order: SVU that involved a schizophrenic who appeared to have killed the woman who was in charge of his group home. No one trusted him and he was in a panic for the entire episode. Until the person who murdered the woman murdered him. I rarely cry watching law shows. I bawled.]

Most schizophrenics probably don't want schizophrenia. But what if they don't mind it? Similarly, most people with bipolar disorder I don't want it, but what if they don't mind it? Should we medicate people? And when we do, are we actually doing it to protect others? Or are we just doing it to quiet an imperfection, an imperfection we are holding on with us and projecting onto the larger world? I think this is especially a problem for doctors, who control so much power to change a person's life. Wouldn't it be best to understand what quality of life such a person wants first?

Monkey Kidneys & Ethics

Surprisingly, monkey kidney cells are very expensive (I am being sarcastic). What kind of underworld, black market shady dealings do you have to perform to get "monkey kidney"? I presume very unseemly indeed if the acquired monkey kidney tissue is frequently unreliable.

Basically my question is, can you kill monkeys in America?
And if yes,
were these monkeys free range?

Penultimate Bioethics Post

Haven't put anything up in a relatively long time, so here's something I just wrote for Bioethics. I do not know if it's very good (and in fact I am fairly sure my citations are incorrect), but it is incredibly interesting. We had to read an article and analyze it with bioethical principles. The article itself was amazing. I, too, hope to one day get my writing into NEJM or JAMA. 

In the New England Journal of Medicine's article, "Up in the Air -- Suspending Ethical Medical Practice", a physician recounts his experience on a plane in which a fellow, older passenger goes into cardiac arrest. There are a total of five physicians on the plane, and they all gather around the man to perform CPR. 

The problem arises when, after twenty-five minutes of basic life support (BLS) and attempted resuscitation, the man is still dead. As physicians, they decide to "declare the patient dead" (Shaner 2010); unfortunately, the airline they are flying on has a protocol that requires the flight attendants to continue resuscitation attempts until the plane lands if no one more qualified can do it. So the author and his wife (also a physician), continue to run BLS on a man who is clearly dead. 

The author goes into a beautiful explanation of why he was essentially forced to continue doing something that was futile in order to placate a company's protocol. I think that this situation brings up three good points that we've talked about in this course:

1) Kantianism

Here we must acknowledge that the actions the physician found himself having to go through had no real benefit to the "patient's" health and indeed were done not for a moralistic reason. "… to have moral worth, a person's motive for acting must come from a recognition that he or she intends that which is known to be morally required" (Beauchamp & Childress 344). But the physician, and indeed, all five of the physicians on the plane, did not recognize the continuation of BLS as being morally required. At one point, the author notes that a surgeon had left as soon as they had all been made aware of the company's protocol, saying "This is futile" (Shaner 2010). Thus an argument could be made that the remaining physicians continuing BLS were acting amorally (without morals). "If agents do what is morally right simply because they are scared, because they derive pleasure from doing that kind of thing, or simply because they seek recognition, they lack the requisite goodwill that derives from acting for the sake of obligation" (Beauchamp & Childress 344). The author acknowledges that it was not the best moral option to continue CPR, saying "to prolong [it] under the circumstances in which we found ourselves would be to subvert medicine's goal from the good of the patient to the benefit of the community" (2010). 

2) Contextual Features

What caused the author to continue BLS was not his own moral code (he was very much against it), but rather, the context in which the situation was occurring. Had the event taken place in public, rather than on private property, the physicians involved probably would have little trouble ceasing BLS when deemed inappropriate, or, as the author put it: "CPR should be deemed ineffective when it cannot be expected to meaningfully alter the natural course of the disease…" (2010). Unfortunately, "every medical case is embedded in a larger context of persons, institutions, financial and social arrangements. Patient care is influenced, positively and negatively, by the possibilities and the constraints of the context" (Jonsen, Siegler & Winslade 1998). The most affective context in this story is the institutional one. The author says, "We had knowingly delivered medically ineffective CPR. But we did so because of practical concerns arising from the demands of the airline's protocol" (2010).

3) Discernment

In the end, the author firmly believes that medicine and practitioners of medicine should have their own policies that supersede whatever social policies and protocols they may come up against. This is the thesis of the essay, and I believe this whole story is a very practical demonstration of the importance of discernment. In a way, discernment also echoes some of the features of Kantianism. Discernment requires physicians to "… make fitting judgements and reach decisions without being unduly influenced by extraneous considerations, fears, [etc]" (Beauchamp & Childress 40). The fear of litigation is what caused the airline company to create a protocol which in the end proved to be morally damning in this specific case. The airline may have lacked discernment for this and similar health issues, but physicians are more able to understand what is necessary in terms of health outcomes without worrying over "extraneous considerations." This is because all physicians should, over time, develop "practical wisdom," which is essentially a deep understanding of the situation from a purely health perspective. When we get bogged down by social concerns, we become more at risk for biasing our actions. In the end, the author concludes explicating a very thoughtful idea that I also hold quite fervently: "We should ensure that our medical policies and protocols exclude considerations such as mitigation of liability or the exclusive interests of third parties from playing a role in resuscitative decisions. Such policies will help support the efforts of physicians to act always for the good of the patient and within the bounds enunciated in the Hippocratic Corpus" (Shaner 2010). 

1. Beauchamp TL, Childress JF. Principle of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009. 

2. Albert R. Jonsen, Mark Siegler, and William J. Winslade. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 4th edition. New York: McGraw-Hill, Inc., 1998. 

3. D. Malcolm Shander, M.D. "Up in the Air -- Suspending Ethical Medical Practice." New England Journal of Medicine vol 363; 2010.

Bioethics Self Challenge: How Ridiculous Can I Get?

Well, after challenging myself to write something more ridiculous than that one time when I wrote, "I think we can assume that this family is evil," I wrote something more ridiculous in the following hour. For context, I will say that we have to discuss health care issues using principles of biomedical ethics we have read about. I would elect to only read the bold, but sure, you can read everything else too.

Should it be legal for people to buy organs for transplant, if they would not be able to receive an organ by waiting their turn through the national database? 

This is an issue that involves Justice. Essentially, if we allowed people to buy organs instead of organizing everyone onto a wait-list, we would be defining wealth/capital as a relevant property. Relevant properties are defined as conditions/things "that persons must possess to qualify for a particular distribution" (243). In this case, "particular distribution" refers to organs for organ transplantation. As much as I would like to say I know what the relevant property for currently receiving health care in America is, I do not have a full enough understanding of health insurance to posit more than a few tentative ideas.  

Oh god, and then there's like three different main types of health care, so I should not begin to discuss this.  

Regardless, I think that changing the relevant property/requirement for receiving organ transplants is antithetical to the way medicine wishes to be practiced in this country. I think this is why less than 20% of the physicians surveyed thought it would be okay for people to buy organs that they may not otherwise receive. It is unfortunate that some people may not receive organs, but if it is something that is going to happen regardless, this grave misfortune should befall everyone equally. 

I also believe that changing the system into a monied one would simply make the process of organ transplantation much more complicated. 

More practically, it also feels wrong to treat transplantations in this fashion. I would argue that by failing to keep justice equally distributed among all persons, you are allowing maleficence to occur. Example! Let's say child Batman and child Spiderman both need liver transplants. Well, little Bruce Wayne (Batman) has really rich parents while orphaned Peter Parker (Spiderman) has only his lower middle class aunt and uncle to look after him. Many arguments have proven that both Batman and Spiderman are of around equal importance to society later on in life. Yet, had this hypothetical situation occurred, and if organs were doled out in accordance with payment and not according to wait lists, little Peter would not have made it. 

By changing the way the system works, and by allowing a subgroup of people to have more power in the system than others, you are creating a social inequality around something as serious as life and death. With great power comes great responsibility, and I do not think that anyone with an ethical mind could easily approve of this level of injustice.   

References:
Beauchamp TL, Childress JF. Principle of Biomedical Ethics. 6th ed. New York, NY: Oxford University Press; 2009.197-199

No Duh Aristotle

Sometimes bioethics can be really dumb, and yet so disturbingly profound.

No, that last half is profoundly sarcastic.

Here is a fun quote from our Bioethics text:

"Common to all theories of justice is a minimal requirement traditionally attributed to Aristotle: Equals must be treated equally, and unequals must be treated unequally."

NO. WAY.
I think my brain just exploded from the complexity of that statement.


But to be serious for perhaps a paragraph, I really enjoy bioethics. I miss writing things out. Also, it's fun to posit ridiculous arguments. However, I don't know if I'll ever write anything more ridiculous than the following sentence I wrote for a discussion on vaccinations:

"I think we can safely assume that this family is inherently evil."
So get your kids vaccinated!