Endocrine Research

The Declaration of Helsinki and What Happened July 16, 2018

July 20, 2018 • By

This month, everyone has started talking about the “declaration” of Helsinki — surprising remarks made on July 16, 2018 by President Trump at his recent historic summit in Helsinki. But before this month, the only professionals who talked frequently about the Declaration of Helsinki, were those involved in biomedical research. That’s because the Declaration of Helsinki refers to the World Medical Association’s ethics guidelines for medical research with human subjects, originally published in 1964 (See: https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/). It is this document that established the need for Institutional/Ethical Review Boards (in its 1975 revision) for research protocol oversight. It’s been revised several times since 1975.

Prior to the Declaration of Helsinki, the only other guiding international document for research ethics with human subjects was the Nuremberg Code, created in 1947 (See: https://history.nih.gov/research/downloads/nuremberg.pdf).

The Declaration of Helsinki largely echoed the Nuremberg Code, but helped to define distinctions between therapeutic and nontherapeutic clinical research. It was first announced on July 18, 1964 in the British Medical Journal, and just had its 54thbirthday this month.

On July 16, 2018 – yes, the same day as that Helsinki summit — another shocking event took place in the U.S. that should concern the World Medical Association. The U.S. Department of Health and Human Services eliminated years of medical knowledge by removing a critical website that housed hundreds of clinical practice guidelines. (See: https://www.msn.com/en-us/news/us/hhs-plans-to-delete-20-years-of-critical-medical-guidelines-next-week/ar-AAzXUJC?ocid=se).  That means all of the clinical practice guidelines you rely on, and used to be able to get at the URL www.ahrq.gov/gam are now gone. Many of the guidelines published by the Endocrine Society or the American Thyroid Association –  intended for a range of primary care practitioners or other specialists — are no longer readily available through the National Guideline Clearinghouse, known for housing bias-free clinical practice guidelines. The National Guideline clearinghouse was created in the 1990s to help ensure that evidence-based medicine was more accessible to the practitioner. The clearinghouse practice guidelines database was maintained by the Agency for Healthcare Research and Quality (AHRQ), on its “Guidelines and Measures” site. Now when you go there, you’ll get the sad message: “Funding to support AHRQ’s National Guideline Clearinghouse (NGC) ended on July 16, 2018.”

The New York Times had this to say:

“The sheer volume of medical information now within a few clicks’ reach can make it difficult, even for doctors, to separate wheat from chaff. Clinical guidelines based on careful consideration and solid impartial research can be difficult to tell apart from those based on weak data, or rooted in a clear conflict of interest (usually a financial stake in whatever treatment they are promoting). The clearinghouse, which not only vets countless sources of medical information but also makes its results easily searchable, is regarded as the most dependable repository of its kind in the world… On [July 16, 2018], the Department of Health and Human Services took it offline, the latest casualty in an administration determined to eliminate science from the government’s agenda….The official explanation is maddening enough: a budget shortfall that roughly equals the amount Tom Price  spent on travel during his brief tenure as department secretary. The site costs just $1.2 million a year to operate, and is maintained by an agency with a budget of more than $300 million. (See:https://www.nytimes.com/2018/07/19/opinion/trump-medicine-data-hhs-ahrq.html)

The World Medical Association’s Declaration of Helsinki was groundbreaking in 1964. It would be a natural extension of this body to take up the task of housing not just the U.S. database of clinical practice guidelines discarded this month by the Trump Administration, but the world’s medical association guidelines so that they are never again vulnerable to the whims of politicians.

 

Pediatric Endocrinology

Stress Hormones and Children: An American Pediatric Ethics Catastrophe

June 27, 2018 • By

The biggest bioethics story this month, and likely the Summer of 2018, involves the physical and emotional trauma being inflicted on children at the U.S. border as a result of a Trump Administration policy of child separations at the border. This was a new policy in which the children of asylum seekers arriving at the U.S. border were being removed from their parent(s), and sent to U.S.-created internment sites that are run by HHS, while the parent is held in custody awaiting either deportation or an immigration hearing. Although these child internment sites have been described in reports as “humanely run,” since the policy of separating children from their parents is not humane, the moral harms are self-evident. Notwithstanding, there have been reports by that conditions are unacceptable and alarming. (See: https://news.sky.com/story/hundreds-of-lone-children-kept-in-cages-in-us-border-patrol-prison-11408321.) 

Whistleblowers have also made some material available for the public interest, including an audio recording released by ProPublica that demonstrates the emotional trauma of the separated children: (See: https://www.propublica.org/article/children-separated-from-parents-border-patrol-cbp-trump-immigration-policy.)

By mid-June, an American pediatric ethics tragedy was in plain view, particularly in light of news that babies and toddlers are being interred in “tender age” facilities (See: https://apnews.com/dc0c9a5134d14862ba7c7ad9a811160e.) Seasoned reporters, in fact, became “unglued” with moral distress when they read the Associated Press report on-air.

To any pediatric healthcare provider, the pediatric healthcare issues are well-known. In the field of pediatric endocrinology, the effects of stress hormones on children are well known and documented. (See, for example: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3574783/  or http://stke.sciencemag.org/content/5/248/mr1.full.) When children suffer emotional trauma, there are irreparable physiological changes and changes to the brain.

The American Association of Pediatrics published the following statement: https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/StatementOpposingSeparationofChildrenandParents.aspx

The American Psychological Association published this statement: http://www.apa.org/news/press/releases/2018/05/separating-immigrant-families.aspx

The American Psychiatric Association published this statement, along with several other mental health organizations: https://www.psychiatry.org/newsroom/news-releases/apa-statement-opposing-separation-of-children-from-parents-at-the-border

The Bioethics community published this statement: http://www.bioethics.net/2018/06/child-abuse-as-immigration-policy-has-america-lost-its-moral-compass/

The current Attorney General of the United States has defended the policy as being sanctioned by the “bible”. (See: https://www.washingtonpost.com/politics/sessions-cites-bible-to-defend-separating-immigrant-families/2018/06/14/7b20b9fa-7014-11e8-b4d8-eaf78d4c544c_story.html?utm_term=.4ea07ec68e7f.) The White House architect of the child separation policy, boasts that it is a “deterrent” for immigration and proof that the Trump Administration is strong on border security. (See: https://www.bostonglobe.com/opinion/editorials/2018/06/19/stephen-miller-architect-family-separation-border-must/q7u4GAtQUdbrs1DSMgx0MI/story.html.)

Due to mounting public pressure, an Executive Order to halt separation of families was signed by President Trump, but there is no plan to reunite the children already separated from their families, and confusion over how track them (See: https://www.nytimes.com/aponline/2018/06/22/us/ap-us-immigration-separating-families.html.)

It is difficult to assess the long-term consequences of what can only be called a pediatric ethics catastrophe created by the U.S. government.

 

Transgender Medicine

Transgender and Military Ethics

March 31, 2018 • By

Another ban was issued this month surrounding transgender individuals serving in the military, based on a February report signed by James Mattis. (See: https://news.usni.org/2018/03/23/pentagon-report-recommendations-transgender-troops-serving-military.)

Those diagnosed with gender dysphoria will apparently be subject to the ban. (See: https://www.military.com/daily-news/2018/03/23/new-trump-transgender-military-policy-bars-those-gender-dysphoria.html.) The ban will apply to “persons with a history or diagnosis of gender dysphoria — including individuals who the policies state may require substantial medical treatment, including medications and surgery — are disqualified from military service except under limited circumstances.”

The Pentagon is making the argument that traditional criteria for mental health and stability should apply here. This raises the clinical ethics question as to whether “gender dysphoria” be treated as a mental health issue or an endocrine issue? According to the American Psychiatric Association, gender dysphoria is what distinguishes whether distress is associated with questions about one’s gender identity. (See: https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria.)

According to the White House “The experts’ study [in the February report] sets forth a policy to enhance our military’s readiness, lethality, and effectiveness…[and] concluded that the accession or retention of individuals with a history or diagnosis of gender dysphoria — those who may require substantial medical treatment, including through medical drugs or surgery — presents considerable risk to military effectiveness and lethality.”

Ultimately, the U.S. military is closing its doors to transgender individuals. Eventually, it will probably need to be addressed by the courts, with endocrinologists needing to serve as the experts.

 

Uncategorized

Crisis of Conscience

January 31, 2018 • By

This month, the Trump Administration introduced a mechanism through HHS for healthcare providers to object to performing procedures they find morally distressing or objectionable based on their religion, or as reported:  to “ease the way for doctors, nurses or other medical professionals to opt out of providing services that violate their moral or religious beliefs” (See: https://www.washingtonpost.com/news/to-your-health/wp/2018/01/18/new-hhs-civil-rights-division-charged-with-protecting-health-workers-with-moral-objections/?utm_term=.81912e085354).

HHS will soon create the Conscience and Religious Freedom Division — an entire division devoted to conscientious objection.  The vast majority of bioethicists find this announcement to be cause for concern because it introduces further barriers to healthcare for many groups already disenfranchised or vulnerable, including women needing reproductive healthcare or transgender patients.  But it also violates what bioethicists see as clear duties of care inherent in the medical profession (See: https://www.reuters.com/article/us-usa-healthcare-religion/u-s-government-to-shield-health-workers-under-religious-freedom-idUSKBN1F7262).

I have mixed feelings about this new division, which may become a cautionary tale for the Trump Administration. Moral diversity and “moral objection” swings many directions, and by creating an official conscientious objection division, the Trump Administration must now allow for a wide range of moral protections for practitioners.  In some ways, this could provide unanticipated protections for the very groups the Administration seeks to inconvenience.

First, most hospitals already have these institutional policies in place. As a clinical ethicist, I invoke these policies frequently to protect and preserve the moral integrity of healthcare providers involved in care plans they find objectionable. I have rarely invoked these policies, however, for objections on religious grounds. I have mostly used them to relieve moral distress over medically inappropriate care plans in which limits to autonomy have not been properly asserted or championed by the institution, such as in situations where surrogates are demanding treatments that make no medical sense, and practitioners feel they are crossing ethical lines to appease surrogates. I have also invoked these policies to excuse practitioners from being forced to care for patients who have personally threatened them or their families, which sometimes includes situations where patients or surrogates are making personally racist statements, or when hateful misogynists make statements against their female doctors. In the Trump Era, healthcare providers newly exposed to racist comments are immigrants with accents from all parts of the world – many of whom are permanent residents or U.S. citizens.

In many of these cases, conscientious objection has worked well; in most institutional policies, there is a  mechanism for transfer of care or referral, and in extreme situations, transfer care to the Chief Medical Officer. Thanks to the Trump Administration, practitioners who experience racist patients, can now use the HHS’ new division to “object to care” on moral grounds. White supremacist patients, or patients who are anti-immigration, may be in for a shock when their practitioners “object” to caring for them because the patients’ personal views violate their moral integrity. Alternatively, practitioners who don’t believe women are equal based on their religion, for example, may decide that they don’t want to work with female colleagues in a secular environment and invoke “conscientious objection” to having to converse with another female colleague. The Trump Administration may become mired in all kinds of sticky cases arising from conscientious objection that has nothing to do with reproductive care. Could LGBT practitioners “object” to being forced to caring for patients who don’t support LGBT rights? Or, in a politically divisive country, perhaps Democrats can now morally object to caring for Republican patients, or vice versa. What might count as a legitimate claim of moral objection? Good luck with that.

A  2012 law review piece by Paul-Emile suggests that we should make every effort legally and ethically to  accommodate any patient’s request to see a different practitioner — even if the grounds are racist (See: https://www.uclalawreview.org/patients’-racial-preferences-and-the-medical-culture-of-accommodation/) as neither the practitioner nor patient is served when there is a breakdown in patient-practitioner trust.

Transfer of care or referral is an important caveat in any ethical conscientious objection policy, and the HHS’ new division will be no exception. In cases where the objector refuses to transfer care because of claims of “moral complicity”, this is where such policies become unworkable. I’ll be looking carefully for that “parachute clause” in the division’s language.

So, in response to the new HHS entity: conscientious objection swings both ways. Most of the care providers will object to care plans that probably have nothing to do with reproductive care. This new, controversial division may lead to a tsunami of moral assertions that block access to care for its most enthusiastic supporters because they may not realize that some of their own moral assertions may not be shared by the practitioners they will confront in the real world.

 

Reproductive Endocrinology

2017: Year of Women’s Reproductive Rage

December 30, 2017 • By

If you’re an endocrinologist with patients in their reproductive years, then here is a prescription for mandatory viewing: Hulu’s The Handmaid’s Tale, which is to reproductive justice what the 1997 film, Gattaca was to genetic sequencing. Part cautionary tale, and part “we’re practically there.” And soon, “Um…that actually happened last week.”

The premise of the series is that in the wake of decades of unregulated environmental toxins, most American women are now sterile; a small minority are able to conceive. Meanwhile, the political structure of the U.S. deteriorates into an authoritarian state ruled by Christian fundamentalists who assign roles to the females in the population: some are the “wives” of the ruling class in traditional marriages where women are subservient to males; some are forced “domestics” (the cooks and housekeepers); some are forced into reproductive service as “handmaids” to the infertile couples. Handmaids must submit to unconsensual intercourse with the male heads of households to which they’re assigned, with the goal of serving as surrogate birth mothers for the infertile ruling class. What about the lesbians? They are “gender traitors” who have forced clitoridectomies. (For more analysis of the series, see: https://www.newyorker.com/magazine/2017/05/22/a-cunning-adaptation-of-the-handmaids-tale).

Based on the 1985 novel by Margaret Atwood, The Handmaid’s Tale asks a central question in the Trump era: Do women have autonomy or not? And, by extension, do women’s voices mean anything?

In 1985, Atwood was initially writing the novel in the context of the Reagan era, and the “moral majority” which was a movement that inspired her fictional and futuristic version of the United States in which the Constitution is dissolved by a far right, Christian militia, renaming the U.S. “Gilead”. Here is a 1981 New Yorker piece on the burgeoning “moral majority” entitled “A Disciplined Charging Army”: https://www.newyorker.com/magazine/1981/05/18/a-disciplined-charging-army

The 1980s “moral majority” was a feminist backlash movement that wanted to stop women’s social and reproductive progress, which it saw as a threat to the traditional family. But The Handmaid’s Tale was also written during the burgeoning era of artificial reproductive technologies (ART), such as IVF and surrogate motherhood. The “moral majority” eventually became the base of the Republican Party, which now operates all three branches of government. In 2017, to satisfy its base, we watched the Republican Party disband its Constitutional duties of oversight to cede control to the Executive Branch. We watched, too, as our democratic norms once “guaranteed” under the U.S. Constitution eroded. Now, we are living in a time in which the U.S. Congress is actively enabling an authoritarian, illiberal President of questionable decision-making capacity. Ultimately, the Trump era is one where anti-feminist, anti-civil rights, anti-science, and anti-evidence-based policies are fast becoming normalized. Legislators who are proponents of the Trump agenda pride themselves on restricting women’s reproductive rights and the civil rights of the LBGT community; the President is actively trying to ban transgender persons from military service (See: http://endocrineethicsblog.org/the-presidents-gender-bender/)

Of course, erosion of women’s reproductive rights did not happen overnight; state legislatures have been in Republican control for several years due to low voter turnouts in local and mid-term elections during the Obama era. A myriad of abortion restrictions and TRAP laws were introduced between 2011-2016 (See: http://endocrineethicsblog.org/2016/06/), but over 400 more abortion restrictions were introduced in 2017, with some states requiring completely unethical statements be made to the patients seeking the procedures, including (in Utah) a requirement that doctors attempt to medically rescue aborted fetuses when they are removed from the womb. (See: http://www.motherjones.com/politics/2017/04/guttmacher-report-abortion-restrictions-proactive-legislation-first-quarter-2017/#). In April, President Trump signed a new law to withhold public funds used for family planning (see: https://www.npr.org/sections/thetwo-way/2017/04/13/523795052/trump-signs-law-giving-states-option-to-deny-funding-for-planned-parenthood)

Earlier this month we learned that the Trump Administration has now banned the CDC and the Department of Health and Human Services from using certain words, such as “evidence-based”, “fetus” and “transgender”. (See: https://www.washingtonpost.com/national/health-science/cdc-gets-list-of-forbidden-words-fetus-transgender-diversity/2017/12/15/f503837a-e1cf-11e7-89e8-edec16379010_story.html?utm_term=.d1971c7307a8).

Ultimately, despite so many political distractions, 2017 was a very productive year for the erosion of women’s reproductive and civil rights.

On January 21, 2017, the year began with the Women’s Marches across the U.S., and in many other countries the day after the 45th President of the United States was elected despite his statements on video that he could “grab women by their pussies” whenever he wanted. The iconic symbol of the Women’s Marches became the pink “pussy hat”. But as the year progressed, policies targeting women have been a key part of the Trump agenda. Here is a summary of legislation on the menu in the first 100 days: https://www.americanprogress.org/issues/women/reports/2017/04/25/430969/100-days-100-ways-trump-administration-harming-women-families/).

Additionally, there were multiple attempts to repeal the Affordable Care Act and remove basic access to women’s health. (See: http://endocrineethicsblog.org/kill-bill-volume-1/)

But the most significant achievement in eroding women’s rights was the appointment of Neil Gorsuch to the “stolen” Supreme Court Seat. Gorsuch, a conservative judge, remains a threat to Roe v. Wade. The Trump Administration has also been very busy installing conservative judges on the federal courts (https://www.nytimes.com/2017/11/11/us/politics/trump-judiciary-appeals-courts-conservatives.html), who will surely help to rule in favor of laws that erode women’s reproductive rights and justice in the future. For now, the federal courts have held that women still have reproductive rights. But that could change quickly, particularly with the current Attorney General at the helm, who would feel right at home in “Gilead”. Alas, even if Trump gets impeached, the current Vice President is a character right out of “Gilead”, too. Under a potential Pence Administration, a Gileadian future is even more possible. We have already seen some foreboding signs this year. Undocumented pregnant women have been held against their will by the Justice Department, and prevented from accessing constitutionally protected abortions. In one case, even when the ACLU attorneys ultimately won the case for an undocumented teen to get an abortion, the Justice Department started suing the ACLU’s attorneys. See: https://www.washingtonpost.com/politics/courts_law/undocumented-immigrant-teen-has-abortion-ending-weeks-long-court-battle/2017/10/25/9805249a-b90b-11e7-9e58-e6288544af98_story.html?utm_term=.6930202c44b6

and

https://www.huffingtonpost.com/entry/doj-aclu-jane-doe-undocumented-teen-abortion_us_59fb213be4b0b0c7fa387271

As for Atwood’s dystopian premise of environmental toxins interfering with fertility, that story has been ongoing since the discovery of endocrine disruptors (see: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3845732/) in the wake of weak regulations on organochlorines. Although the Obama Administration began to implement stricter regulations on environmental threats, in 2017 the EPA was effectively dismantled, and its scientists silenced, by the new anti-EPA director, Scott Pruitt. (See: https://www.pbs.org/wgbh/frontline/film/war-on-the-epa/). Between the destruction of the EPA, and the President’s exit from the Paris Climate Accord, it’s “deregulation gone wild” as polluters are granted the freedom to let loose. There is no telling how environmental deregulation will affect reproductive health; children’s health, and public health in general.

We are closer to The Handmaid’s Tale than you think, but there are signs that women are beginning to use their rage to prevent a future that is so tangible, we can taste it. The #MeToo Movement, which erupted in the Fall, closed the year, as women started to call out by name their sexual predators, sexual harassers and uninvited gropers, putting an end to several prominent males’ careers. It remains to be seen if there will be a male backlash. But we need to remember that right now, women’s civil and reproductive rights hang by a thread.

Atwood stated that The Handmaid’s Tale was an “antiprediction” because “if this future can be described in detail, maybe it won’t happen.” Indeed 2017 paved the way for women’s reproductive rage to translate into real legislative power. In Virginia, women were responsible for nearly flipping the state legislature by running for local office and voting out white males. In Alabama, African American women, in particular, were responsible for staving off a white male predator who meets the legal definition of a pedophile, and even stated he was pro-slavery.

The Handmaid’s Tale is too close for comfort; but 2018 may become the year women literally run for their lives (and reclaim their reproductive autonomy). One thing is certain: women will no longer accept “Lock Her Up” when they ask for power.

 

 

 

 

 

 

 

 

 

 

Uncategorized

Price Fixing: Lessons in Moral Integrity

September 30, 2017 • By

This is an “I told you so” that ethicists have seen many times. When you find ethical integrity problems once with an individual – especially a physician — it is indicative of a larger pattern. To that end, Dr. Price’s ethical misconduct surrounding his extravagant travel tastes should come as no surprise to anyone — considering that he already was found to be self-dealing when he was a member of congress. He held stock in drug companies that he personally helped as a legislator. (See: http://www.wsj.com/articles/donald-trumps-pick-for-health-secretary-traded-medical-stocks-while-in-house-1482451061.) Typically, the laws of politics should have prevented his confirmation, but that didn’t happen. He was confirmed as Secretary of HHS by a Republican congress despite his glaring conflicts of interest, questions raised by the Office of Government Ethics (see: http://www.cnn.com/2017/01/18/politics/tom-price-conflicts-interest-oge-ethics-office/index.html), and concerns about his ethical integrity raised during his hearing (see: https://www.nytimes.com/2017/02/10/us/politics/tom-price-health-and-human-services.html). But he was not even unique. Just about everyone in this Administration’s cabinet has something to hide, and is either openly self-dealing or suspected of such. All political ethical norms have been shattered in this Administration, leaving those of us in the ethics business so morally upended, “moral distress” doesn’t seem like an apt definition anymore.

The only thing about Dr. Price’s resignation as Secretary of HHS that is unique is that the laws of political gravity seemed to work in this situation. Secretary Price, who, as it turns out, was not a particularly effective cabinet member, and did not mesh well with the President, was seen as disposable. He made the President look bad, which seems to be the reason he was asked to resign (See: https://www.theatlantic.com/politics/archive/2017/09/tom-price-resigned/541608/). Had the President liked him, and Dr. Price had been successful in helping to gut our healthcare system by leaving millions of Americans at the bottom of the sea, his tenure would have been considered a success, and his travel misdeeds would have surely been excused. I was genuinely concerned that Dr. Price would prove competent in his role, and do the damage he was hired to do (see: http://endocrineethicsblog.org/putting-a-price-on-healthcare/). Dr. Price’s own self-interest and hedonistic tendencies were his Achilles heel. Since he’s an orthopedic surgeon, maybe he can see an orthopedic colleague for that problem.

We will need to do a Price Comparison on his successor, and see if he or she can will end healthcare for millions, or actually heal it, as the Washington Post is hoping for (see: https://www.washingtonpost.com/opinions/the-opportunity-in-tom-prices-resignation/2017/09/30/f4c722f8-a5ee-11e7-b14f-f41773cd5a14_story.html?hpid=hp_no-name_opinion-card-c%3Ahomepage%2Fstory). I predict this Price Fix is only temporary.

Diabetes

Harvey, Disaster Ethics and Diabetes Care:

August 31, 2017 • By

On the 12th anniversary of Hurricane Katrina, another devastating hurricane and flooding situation is ongoing with Hurricane Harvey in the Houston area. But there are some new lessons learned from Katrina when it comes to the impact of hurricanes on people with diabetes: preventative ethics.

On the 10th anniversary of Katrina, I wrote this, which largely reminded us about the terrible health disparities in plain view among a largely African American population of hurricane victims: http://endocrineethicsblog.org/2015/08/

Since Katrina, the endocrine community has become much more aware of the impact of natural disasters when it comes to diabetes care. Here are some “real time” postings in anticipation of Hurricane Harvey, and the large diabetic population that is being affected.

Several diabetes organizations and drug companies are now offering targeted help to people with diabetes, on display here:

https://www.diabetesdaily.com/blog/helping-hurricane-harvey-victims-with-diabetes-477597/

https://diatribe.org/hurricane-harvey-diabetes

http://www.jdrf.org/press-releases/american-diabetes-association-jdrf-insulin-life-respond-catastrophic-flooding-due-hurricane-harvey-texas/

With more hurricanes to come in 2017, diabetes disaster planning, at least, has gotten a little better from the painful lessons of Katrina. But how many hurricanes will it take for there to be recognition that climate change is a public health menace, requiring major reform in carbon emissions policy? “The answer, my friend, is blowin’ in the wind…”

Transgender Medicine

The President’s Gender Bender

July 31, 2017 • By

It’s not unusual for the 45th President of the United States to go on a Twitter “bender” when he is unsupervised. But this month, one of his benders hit the endocrine community hard, when, on July 26, he tweeted:

“Please be advised that the United States Government will not accept or allow transgender individuals to serve in any capacity in the U.S. Military…Our military must be focused on decisive and overwhelming victory and cannot be burdened with the tremendous medical costs and disruption that transgender in the military would entail.”

The announcement effectively blindsided the military, which did not have plans to re-instate any such ban, and its response was swift: the military challenged the President to an intellectual exercise of drafting coherent policy that would (a) justify the ban; and (b) communicate a process. Until and unless that occurs, the military announced that transgender individuals should not be concerned about being kicked out of the military. According to the New York Times: “In a letter to the military service chiefs, Gen. Joseph F. Dunford Jr., the chairman of the Joint Chiefs of Staff, said that the policy on who is allowed to serve would not change until the White House sends the Defense Department new rules and the secretary of defense issues new guidelines. His letter stated that: “In the meantime, we will continue to treat all of our personnel with respect,” (https://www.nytimes.com/2017/07/27/us/politics/transgender-military-trump-ban.html)

Aside from the problem of dictating policy through Twitter, and the fact that it was announced on the anniversary of Harry Truman lifting the ban on African Americans serving in the military (see: https://www.vox.com/identities/2017/7/26/16034656/truman-integration-military-trump-trans), the proposed ban is not based on sound medical reasoning. According to the American Medical Association (see https://www.ama-assn.org/ama-statement-transgender-americans-military): “There is no medically valid reason to exclude transgender individuals from military service. Transgender individuals are serving their country with honor, and they should be allowed to continue doing so.”

According to a 2016 RAND Corporation study, as many as 15,000 active-duty troops may be transgender, and “have minimal impact on readiness and health care costs” for the Pentagon.

The response to the tweet was swift: the medical community issued a strong rebuke (See:

http://time.com/4875375/transgender-ban-military-doctors-react/). The public’s response – Republicans and Democrats alike — made clear that the ban was morally unacceptable, and several Republicans in Congress swiftly denounced the ban.

The main issue is the costs of gender-transition surgeries, which the Obama administration considered carefully, and decided to cover. The justification was that the costs of $2.4 million and $8.4 million annually for transition-related medical care was a drop in the bucket when compared to medical costs for the myriad of other conditions treated (see: https://www.nytimes.com/2015/06/09/opinion/what-doctors-say-about-transgender-troops.html). A study published in The New England Medical Journal (see: http://www.nejm.org/doi/full/10.1056/NEJMp1509230) concluded that “doctors agree that such care is medically necessary.”

Care for transgender patients represents a military health-care spending increase of 0.04 to 0.13 percent, which is one tenth of the annual budget of roughly $84 million the military spends on medication for erectile dysfunction. (See: https://www.theatlantic.com/health/archive/2017/07/things-that-cost-more-than-medical-care-for-transgender-soldiers/534945/)

Slate Magazine conducted an interview with Jesse Ehrenfeld, M.D., an expert in transgender health care and military service who stated: “There are some poorly done studies involving mental health that have been cited to suggest that trans individuals are at heightened risk of suicide or other mental health challenges solely because they are trans. That’s misinformation. There’s good emerging data demonstrating that when we provide a supportive environment and good high quality care to trans individuals, those issues seem to go away and people do well.” (See: http://www.slate.com/blogs/outward/2017/07/28/jesse_ehrenfeld_on_trump_s_transgender_troops_ban.html

Clearly, there are a myriad of ethical and constitutional problems with the President’s tweet; it echoed uncomfortable policies such as the ban on African Americans serving in the air force because of the risk of sickle cell (see: https://www.ncbi.nlm.nih.gov/pubmed/2197408)

Those who are oppose transgender troops raise concerns about psychological fitness, and whether mixing transgender troops into the traditional military population of troops is a social experiment. (See: https://www.nytimes.com/2017/07/26/us/politics/trump-transgender-military.html?_r=0)

If we’re going to use the “psychological fitness” argument, we need to consider the psychological fitness of a Commander –In-Chief who has poor impulse control on Twitter.

 

 

Healthcare Access

Kill Bill, Volume 2

June 30, 2017 • By

Well, it’s time to bite our nails again over the Senate’s version of the “Kill Bill” called the Better Care Reconciliation Act of 2017. The name is deceiving because if passed, this bill will kill thousands of American citizens by denying them affordable access to healthcare, and dramatically altering Medicaid, which may leave many populations devastated. Drafted by only white, Republican males, this bill targets our vulnerable populations: the poor, the old – particularly those in nursing homes — the mentally ill, the disabled, pregnant women and their unborn children, and even NICU patients. (See: https://www.nytimes.com/2017/06/22/us/politics/senate-health-care-bill.html?hp and https://www.nytimes.com/2017/06/23/opinion/senate-obamacare-repeal.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region&region=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region).

The bill will allow states to opt out of covering vulnerable populations and essentially defunds Medicaid. It also eliminates caps on what insurance companies can charge people with complex health needs, and allows insurers to at least double what older people pay.

Here are the details of the bill: http://www.politifact.com/truth-o-meter/article/2017/jun/25/whats-senate-health-care-bill-here-are-five-key-pr/

Here is a nice summary by Atul Gawande: http://www.newyorker.com/news/news-desk/how-senates-health-care-bill-threatens-nations-health

Let’s be clear: this bill amounts to population control based on social Darwinism: the survival of the fittest. If you’re economically advantaged and can afford the ransom the insurance companies can now exact from this bill, you get to live. If you’re physically fit and free from chronic disease or disability, you get to live. The Republican Party argues this bill is “better” because you get to have “choices” the freedom to choose from a variety of unaffordable or inaccessible plans that will punish patients for their pre-existing conditions, and punish women for requiring prenatal and maternity care services. So if you like your healthcare, too bad – because you probably can’t keep it.

If you’re an endocrinologist burdened by too many diabetic patients, rest assured they’ll soon be gone from your practice if this bill becomes law. If you’re struggling with whether it’s more beneficent to observe “low risk” thyroid tumors (a still controversial practice), this healthcare law will remove your dilemma since many new thyroid cancer patients will not have access to treatment anyway.

When a healthcare reform bill drafted by the Republican party is so bad that only about 17% of voters approve of it, and even Republican senators are against it, it’s telling, but also perhaps a sign that reason will prevail with a bipartisan healthcare reform bill in the end. Indeed, if the “Better Care” bill passes, it will be America’s moral stain and shame. Even the American Medical Association states that this bill, as currently drafted, actually violates medical ethics. (See: https://www.forbes.com/sites/brucejapsen/2017/06/26/ama-says-mcconnells-trumpcare-bill-violates-do-no-harm-principle/#1674817b4040 )

Here is the AMA’s letter to Senators McConnell and Schumer, which states “Medicine has long operated under the precept of Primum non nocere, or “first, do no harm.” The draft legislation violates that standard on many levels.” For the full letter, see: https://searchlf.ama-assn.org/undefined/documentDownload?uri=%2Funstructured%2Fbinary%2Fletter%2FLETTERS%2FBCRA-Letter.pdf

Not one single bioethics expert can endorse this “kill bill” – other than the endorsement of killing the bill itself. This bill is the health insurance equivalent of a travel ban – where insurance companies do “extreme vetting” of individuals with pre-existing conditions that will just cost too much to support.

Social Darwinism is not new; it was widely embraced throughout the early 20th century and was the principal framework used to justify gassing the disabled, and other “undesirables” in Third Reich-era Germany. To recall a poignant line from the 2007 film, Sicko, a film that outlined the pre-ACA U.S healthcare system: “May I take a moment to ask a simple question? Who Are We?”

 

 

Healthcare Access

Kill Bill, Volume 1

March 31, 2017 • By

The biggest bioethics story this month was, of course, the “death spiral” of the repeal and replacement of the Affordable Care Act (ACA), known as “Obamacare”.

The proposed replacement law, unveiled as the American Health Care Act (AHCA), was a “Kill Bill” in every way. Under the new law, it was estimated that 24 million Americans who currently have health insurance and access to healthcare, would have lost their coverage. As proposed, the AHCA would have removed the current requirement under the ACA of that mandated coverage for “essential health benefits” comprising 10 services: outpatient care, emergency room visits, hospitalization, maternity and newborn care, mental health and addiction treatment, prescription drugs, rehabilitative services, lab services, preventive care and pediatric services. Republicans argued that such coverage leads to higher insurance premiums.  (See: http://www.vox.com/2017/3/23/15031322/the-fight-over-essential-health-benefits-explained).

Basically, the AHCA, which was being dubbed “Trumpcare” would have removed the requirement to cover what most would define as “healthcare”. Some columnists referred to the proposed bill as “cruel” (See: http://www.gq.com/story/trumpcare-exposed-gop-cruelty). Ultimately, once coverage of pre-existing conditions is removed, people die. (See: http://www.npr.org/sections/health-shots/2017/03/23/521220359/gop-health-bill-changes-could-kill-protections-for-people-with-preexisting-condi?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170323)

But there were many other problems with the bill that would have removed healthcare access, which included restructuring Medicaid, tax cuts, and eliminating the lubricant that allows the ACA to work in the first place: the individual mandate. (See: https://www.washingtonpost.com/blogs/post-partisan/wp/2017/03/24/your-guide-to-the-most-contentious-parts-of-the-gop-health-care-plan/?tid=a_inl&utm_term=.0d36a1dbe10f).

Ultimately, between thousands of protesters voicing opposition to the replacement bill and polling that demonstrated only 17% of Americans were in favor of the proposed replacement bill, the GOP killed the bill, preserving (for now) the ACA. Here are two postmortems from the New York Times:

But the ACA is not “saved”; it remains at risk of being underfunded or sabotaged (See: https://www.washingtonpost.com/opinions/the-real-way-republicans-can-deal-with-obamacare-actually-fix-it/2017/03/24/cef5eba6-10c8-11e7-9b0d-d27c98455440_story.html?hpid=hp_no-name_opinion-card-d%3Ahomepage%2Fstory&utm_term=.eb1a99cec9f0) and http://www.politico.com/magazine/story/2017/03/will-obamacare-really-explode-214949 )

As we ended the month, there were rumblings that there may be another attempt at crafting a Republican healthcare bill, which could be “Kill Bill Volume 2.” (And that may make some heads spin).