Cell 2 Soul: The Humane Health Care Blog

What Does It Mean To Die?

by Rachel Aviv
The New Yorker, February 5, 2018

This fine essay lives at the interface of neurology, ethics and the law. The case in question is that of a 13 year-old African-American girl who bled out after a tonsillectomy on December 9, 2013. “When Jahi McMath was declared brain-dead by the hospital, her family disagreed. Her case challenges the very nature of existence.” This is a complex article, superbly reported, and tragic. It brings to mind the film “Habla con Ella” and the book Beyond the Thin Blue Air.

Here are some excerpts from the New Yorker article.

It is likely that Jahi was in a minimally conscious state, a condition in which patients are partly or intermittently aware of themselves and their environment. Her condition “creates a particular challenge to either disprove or verify, because the likelihood of Jahi being in a ‘responsive’ state during a random examination is small.”

African-Americans are twice as likely as whites to ask that their lives be prolonged as much as possible, even in cases of irreversible coma—a preference that likely stems from fears of neglect.

At St. Peter’s Hospital in New Jersey. The cost of Jahi’s care was roughly a hundred and fifty thousand dollars a week. According to New Jersey’s 1991 statute on death, insurance providers can’t deny coverage because of “personal religious beliefs regarding the application of neurological criteria for declaring death.” Only one other state has a similar law (New York).

A music therapist visited the intensive-care unit every few days. She stood next to Jahi’s bed and played lullabies and soothing melodies on a harp. Nailah observed that Jahi’s heart rate, which tended to be high, would lower when the harpist played. She wondered if her daughter found the songs calming.

Pediatric neurologist D. Alan Shewmon has taken a special interest in her case. When Shewmon was a college sophomore, at Harvard, he listened to Chopin’s Trois Nouvelles Études No. 2, in his dorm room, and the music lifted him into such a state of ecstasy that he had an epiphany: he no longer thought it possible that all conscious experience, particularly one’s perception of beauty, could be a “mere electrophysiological epiphenomenon,” he said. The music seemed to transcend “the spatial limitations of matter.” He went to medical school, in 1971, and then specialized in neurology, because he wanted to understand the relationship between the mind and the brain. In 1997, in a paper called “Recovery from ‘Brain Death’: A Neurologist’s Apologia,” ¹ Shewmon disavowed his earlier views.

Robert Truog, the director of the Center of Bioethics at Harvard, said that once, when he gave an academic talk on brain death, he described it as a catastrophic brain injury, rather than death. A transplant physician stood up and told him, “You should be ashamed of yourself. What you are doing is immoral: to put doubts in the minds of people about a practice that is saving countless lives. I’ve thought long and hard about that. In order to support public trust in the scientific enterprise, I guess I feel that the medical profession is always going to be better off, in the long run, if we speak honestly and truthfully about what we know.”

Recent advances in neuroimaging have led some clinicians to consider the possibility that a significant portion of patients thought to be in a vegetative state—those who demonstrate no overt awareness of their environment and do not make purposeful movements—have been misdiagnosed; they may be periodically conscious and capable of some degree of communication.

Reference:
D.A. Shewmon
Recovery from "brain death": a neurologist's apologia.
Linacre Q. 1997 Feb;64(1):30-96. Full Text.

 

The End

The End is a New York Times series that features essays by people who work in fields dealing with death and dying, like medicine, ethics and religion, as well as personal essays by those who have experienced the death of a loved one.  It started at the end of January, 2015 with a piece by Ira Byock.

The End

The End is a New York Times series that features essays by people who work in fields dealing with death and dying, like medicine, ethics and religion, as well as personal essays by those who have experienced the death of a loved one.  It started at the end of January, 2015 with a piece by Ira Byock.

Who Is My Doctor?

Leana Wen, the new health commissioner of Baltimore, Maryland gave an instructive TED talk  entitled “Who Is My Doctor,” and has famously said, I believe that medicine has maintained its mystique for far too long, and it’s time to open the veil of secrecy and have patients and providers alike participate as equal partners. I believe that patients have to be part of every discussion that takes place in healthcare, from research to system design to medical care.

Physicians need to recognize that we are here to serve the sick. The practice of medicine should not be a means to enrich one’s self at the expense of patients, their insurers of Big PhARMA.  Unfortunately, many physicians are entrepreneurs who have learned to game the system.  Two of the most common ways to do this are by performing unnecessary tests or procedures and by climbing in bed with Big PhARMA.

Recently, the New York Times had an article about unnecessary cardiac procedures and revealed that a Florida cardiologist was paid $18 million by Medicare in 2012, making him the top-billing cardiologist in the country. Over-diagnosis and over-treatment are not problems unique to cardiologists.  Many primary care physicians and diverse specialists have figured out how to game the system at the expense of patients or providers.

Over-diagnosis and over-treatment allow many physicians to make considerable sums from unnecessary tests and procedures.  Actinic keratoses are a source of income for many dermatologists; in addition, innocuous skin cancers are often over-treated by unscrupulous or ignorant providers.

We looked at the billing practices of the six dermatologists in a county of a New England state. All served a similar population of patients. The table shows that in 2012 one practitioner billed Medicare for 20,004 cryosurgeries compared to 214 of these procedures by another dermatologist.  The highest billing  dermatologist in this group collected $940,000 from Medicare for this subset of patients alone.  Medicare is only one insurer for these doctors’ patients.

Bedding Down With Big Pharma is another way that physicians supplement their income.  Some physicians make a tidy sum from giving talks for pharmaceutical firms.  This often takes place at so-called CME meetings.  Two websites  are helpful for tracking these physicians: Dollars for Docs and Open Payments.  Not all companies participate with this reporting. 

As an example, I am aware that in my specialty, dermatology, there are a number of doctors who make over $100,000 a year from Big Pharma (and this is in addition to their regular income from teaching and patient care).  One New York  dermatologist was paid $93,000 just for talks given to other dermatologists in 2013.  These, so-called “key opinion- or thought- leaders” push expensive new medications when older, much cheaper medications would be appropriate. You can look up your doctor at Dollars for Docs or Open Payments.

The akamai patient can research her or his physician at the websites provided below.  These are not perfect resources but they are helpful places to start.

So, perhaps it is time for you to ask, “Who Is My Doctor” and to check up on your favorite providers.

Resources:

1.  Medicare payments to U.S. physicians:  Use this form to find a doctor or other medical professional among the more than 800,000 health care providers that received payments in 2012 from Medicare Part B, which covers doctor visits, tests and other treatments.

2. Dollars for Docs (Propublica): In recent years, drug companies have started releasing details of the payments they make to doctors and other health professionals for promotional talks, research and consulting. As of 2013, 17 companies published the information, most because of legal settlements. Use this tool to search for payments.

3. Open Payments is a federal program that annually collects and makes information public about financial relationships between the health care industry, physicians, and teaching hospitals. The Centers for Medicare & Medicaid Services (CMS) collects information from manufacturers of drugs and devices about payments and other transfers of value they make to physicians and teaching hospitals. These payments and other transfers of value can be for many purposes, like research, consulting, travel, and gifts. CMS will be making this data publicly available each reporting year.

Beyond Religion: Ethics for a Whole World (Audiobook)

Brian Maurer would like to alert you to a FREE AUDIO BOOK, available until December 20.  Beyond Religion, written by the Dalai Lama and read by Martin Sheen, will be free from Audible.com until 12.20!  Is it a come-on?  Does it matter?  If you listen to books, this is a great opportunity.  Go to: Beyond Religion Audible.

Product Description from Amazon:  "A stirring call to move beyond religion for the guidance to improve human life on individual, community, and global levels—including a guided meditation practice for cultivating key human values. Beyond Religion is a blueprint for all those who yearn for a life of spiritual fulfillment as they work for a better world.

In Beyond Religion, the Dalai Lama elaborates and deepens his vision for the nonreligious way. Transcending the mere "religion wars," he outlines a system of secular ethics that gives tolerant respect to religion—those that ground ethics in a belief in God and an afterlife, and those that understand good actions as leading to better states of existence in future lives. And yet, with the highest level of spiritual and intellectual authority, the Dalai Lama makes a claim for what he calls a third way. This is a system of secular ethics that transcends religion as a way to recognize our common humanity and so contributes to a global human community based on understanding and mutual respect."

Go For It!!