Menopause

The Power of Postmenopause

July 30, 2016 • By

On July 29, 2016, at age 68, Hillary Clinton accepted the democratic nomination for President of the United States. Yes, she is a woman of a certain age. The benefits of her being a woman in politics post-menopause became the subject of a Time article by Dr. Julie Holland last year that spiraled out of control: http://time.com/3763552/hillary-clinton-age-president/?xid=emailshare

The point of the article was to provide some medical facts about postmenopausal women in the face of harmful perceptions that women are somehow hormonally incapacitated past menopause. One of the points made was to emphasize that women are now living one-third of their lives post-menopause to an average age of 81, which means that even if elected President in November, Hillary easily has four more years with good preventative healthcare (notwithstanding my concerns about her thyroid medication earlier this year: http://endocrineethicsblog.org/why-hillary-clintons-thyroid-needs-healthcare-reform/).

Whether endocrinologists agree with the facts in the Time article is another story, but in 2015, the first set of evidence-based guidelines authored by women were published by the Endocrine Society on the treatment of menopause. See: http://press.endocrine.org/doi/pdf/10.1210/jc.2015-2236 and http://endocrineethicsblog.org/ethics-of-authorship-whats-so-new-about-the-upcoming-clinical-practice-guidelines-for-menopause-they-were-written-by-women/

The theme of the practice guidelines is to offer individualized therapies to peri- and postmenopausal women, as it is clear that one size does not fit all, and there are a myriad of biological variations of menopausal symptoms and age-related risks.

Several of Hillary’s critics argued that Holland unfairly championed the nominee’s age when, previously, male nominee’s ages had been questioned. Ronald Regan famously said at age 73 at a 1984 debate: “I will not make age an issue of this campaign. I am not going to exploit, for political purposes, my opponent’s youth and inexperience.”

But there has never been a female nominee for the U.S. Presidency before, which makes the issue of Hillary’s postmenopausal achievement personal for many women. The feminist adage, “the personal is political” has perhaps never been so pronounced as it is in this election. Given that her opponent, Donald Trump (70) has made menstrual periods a reason to discount a critical female journalist (“She had blood coming out of her…wherever”), when his “gloves come off,” as he announced yesterday (see: http://www.cnn.com/videos/politics/2016/07/30/trump-gloves-come-off-carroll-dnt-ac.cnn), will Hillary’s hormonal status become a major political issue? Certainly her voice has (See: http://www.huffingtonpost.com/entry/complaining-hillary-clintons-voice_us_579add5de4b0693164c0b55c?section), which is also a biological feature associated with menopause: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991439/

Hillary wore a white pantsuit, which was an historical nod to the Suffragette movements in Britain and the U.S. (See: http://qz.com/745349/hillary-clintons-all-white-pantsuit-at-the-dnc-recalls-centuries-of-american-feminist-history/). It’s critical to note that women’s reproductive status and rights were always at the center of being denied the vote, or in participating in the political process. (See: https://www.americanprogress.org/issues/women/news/2013/08/26/72988/womens-equality-day-celebrating-the-19th-amendments-impact-on-reproductive-health-and-rights/).

But there is also evolutionary power that comes after menopause. Evolutionary biologists propose that menopause favors natural selection because women are biologically more secure once they are no longer vulnerable to the risks of pregnancy and childbirth: http://phenomena.nationalgeographic.com/2013/04/18/why-menopause/

This has been self-evident in the story of American politics. As living conditions and reproductive justice improved for American women – both occurred precisely because they participated in politics. And then so did their lifespans. In 1992, there was a population explosion of menopausal women who were Boomers (see: http://www.nytimes.com/1992/10/21/opinion/mighty-menopause.html). This is Hillary’s cohort (Hillary was 45 in 1992, and just becoming First Lady). Nancy Pelosi, the first female House Speaker, was born in 1940, and began her career when she was elected in 1993 (age 53).

Women’s careers in politics are usually not possible until their childrearing years are over, given the demands parenting places on women’s time.

Whatever the opinions are about Hillary and trust, it’s impossible to deconstruct the public attitudes about Hillary without being entangled in gender bias, which becomes particularly brutal past menopause. As difficult as it is for our appearances to become objectified as young women, aging on a very public stage is not pleasant for women when their wrinkles, “cankles”, cellulite, and adiposity become part of someone’s debate prep. Carly Fiorina (61) is another case in point, when Trump remarked that she had an ugly face during the primary season (see: http://www.huffingtonpost.com/entry/donald-trump-carly-fiorina_us_55f17d22e4b03784e2781531). That remark dominated the news just when Fiorina was being praised for her oratory skills, which stood out against her 17 male opponents. Once her face was up for debate, her popularity plummeted, even as the remark was criticized.

Today, we have about a greater than 50% chance of electing the first female President, an achievement that would be virtually impossible for any pre-menopausal woman, given our social arrangements. In fact, all glass-ceiling breakers who came before Hillary were also women of a “certain age”. Golda Meir was 71 when she became the first woman Israeli Prime Minister in 1969. Margaret Thatcher was 54 when she became Britain’s first female Prime Minister; she was the longest serving Prime Minister of the 20th century (1979-1990).

The question for Hillary and the country is really this: are there enough American women voters past menopause who will support her, given that young women leaned toward an even older Bernie. (His shouting was not an issue for his supporters.)

Elections are no longer determined by white men; they are dying out: http://www.nytimes.com/2015/11/03/health/death-rates-rising-for-middle-aged-white-americans-study-finds.html?_r=0

So the power of postmenopause in 2016 isn’t just about the nominee. It’s about one of the largest voting blocks: female baby boomers who are not going to “Boo” but vote. Amid hot flashes and all, they will “feel the burn” for a political revolution that could put the women in charge, now that Theresa May (59) has become the second female British Prime Minister.

 

 

Reproductive Endocrinology

Undue Burden Aborted

June 30, 2016 • By

June 27, 2016 will stand as one of the most important SCOTUS decisions surrounding reproductive justice and women’s health since Roe v. Wade. I’ve previously blogged about Targeted Restrictions on Abortion Providers, or TRAP laws (See: http://endocrineethicsblog.org/why-biology-is-destiny-in-a-republican-world/). These laws essentially sentence vulnerable or impoverished women to parenting by removing access to pregnancy termination services. Typically, these laws are particularly punishing to women in poverty who were raped or abused, who are unable to travel far.

As of now, the Supreme Court has ruled that these TRAP laws are unconstitutional and pose an undue burden on women seeking safe and legal abortion, which remains their constitutional right.

A fuller exploration of these laws from the perspective of women’s healthcare providers can be seen in the documentary film, Trapped, which debuted earlier this month on PBS. Here is the link to the film. You can freely stream it until mid-July: http://www.pbs.org/independentlens/videos/trapped-full-film/

The U.S. Supreme Court ruled that in the Texas case of Whole Women’s Health v. Hellersted , the TRAP laws being challenged had nothing to do with making abortion safer, or making women’s healthcare safer, and everything to do with making abortion access more difficult, and hence, posed an undue burden on a constitutionally protected right for all women. (See: http://www.scotusblog.com/2016/06/opinion-analysis-abortion-rights-reemerge-strongly/)

For more analysis on this major decision, see the following:

http://www.npr.org/sections/thetwo-way/2016/06/27/483686616/supreme-court-strikes-down-abortion-restrictions-in-texas

http://www.nytimes.com/2016/06/28/us/supreme-court-texas-abortion.html

http://www.npr.org/sections/health-shots/2016/06/27/483698407/fallout-from-supreme-court-ruling-against-texas-laws-abortion-restrictions

http://www.reuters.com/article/us-usa-court-abortion-idUSKCN0ZC0JL

It is virtually impossible to find any bioethicist who does not support a woman’s autonomy in the decision of pregnancy termination pre-viability. TRAP laws help to force postponement of termination procedures past viability. These laws also could force women’s health clinics offering termination services to women to close by imposing onerous requirements that generally have nothing to do with patient safety.

This SCOTUS decision validated constitutional protections for women’s reproductive rights and health. And the absence of a ninth Supreme Court Justice didn’t make a difference in this 5-3 decision.

Reproductive Endocrinology

Olympic Sized Concerns over Zika

May 31, 2016 • By

This month a huge story played out regarding the ethical tensions over the Summer Olympics, Zika, and its risks to women in their reproductive years.

Over 150 experts, including physicians, researchers, and bioethicists sent an open letter to the WHO to urge postponing or moving the Rio games. See: https://www.washingtonpost.com/news/to-your-health/wp/2016/05/27/125-experts-say-olympics-must-be-moved-or-postponed-because-of-zika/?postshare=9471464365992776&tid=ss_tw

The letter proposes there are serious conflicts of interest between the WHO and the IOC: http://www.telegraph.co.uk/news/2016/05/28/who-and-ioc-accused-of-cover-up-over-zika-virus-threat-to-rio-ol/

But then there was push-back from the CDC, which argued that there was no scientific basis for cancelling or postponing the games. See: http://in.reuters.com/article/us-health-zika-idINKCN0YH2IT?feedType=RSS&feedName=health&utm_content=buffer21e3d&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

There was also the official response from the WHO and the IOC, stating that the Games will go on as planned: http://motherboard.vice.com/read/zika-olympics-who

But the Director of the CDC expressed shock and moral distress at a different kind postponement: funding for fighting Zika. The U.S. Congress has refused to consider funding at this time. See: http://www.nytimes.com/2016/05/25/us/politics/political-battles-color-congressional-feud-over-zika-funding.html?_r=0

What is really playing out here are organizational ethics games, in which decision-making is affected by multiple conflicts of interest at every segment of this story.

If you’re interested in signing this letter, you can do so at this link:

http://rioolympicslater.org

And by all means, pass the torch by sending the link to this letter on.

 

Thyroid Cancer

Newsflash: Thyroid Cancer Patients who have Surgery have more Surgical Complications

April 8, 2016 • By

In the spirit of last week’s April Fool’s Day, I’d like to point out a paper recently published in THYROID from a Japanese group by Oda et al that’s been getting a lot of buzz: http://www.ncbi.nlm.nih.gov/pubmed/26426735

This paper’s premise is to track the surgical side effects and complications (including scarring) of thyroid cancer patients with papillary microcarcinoma (PMC) who have surgery and then compare that to the treatment side effects in thyroid cancer patients with PMC offered “observation” instead. Guess what the results were? [Spoiler alert:] Yes, the PMC patients who have surgery have more surgical complications than patients who don’t.

It’s natural to ask whether there was any other point to this paper. For example, did the authors actually evaluate the long-term complications that can occur when a biopsy-proven thyroid cancer that is not surgically removed metastasizes? No. The patients were only followed for a median of 4 years in the context of a disease where recurrence may not be seen for decades. And they were only followed with ultrasound and thyroid function tests, which is not sufficient to conclude whether patients eventually developed distant metastases (radioactive iodine cannot be used as a therapy or diagnostic tool in patients who do not have surgery). Among the patients who did have surgery, many had merely a lobectomy, which also precludes any radioactive iodine follow-up. So in the end, the claims that the “oncological” outcomes were similar in the patients who had surgery and those who did not, cannot be known and cannot be stated. Since all aggressive, poorly differentiated thyroid cancers start out in each person as a “microcarcinoma” you can’t predict which PMCs will spread to distant sites.

See: http://www.ncbi.nlm.nih.gov/pubmed/26109472 and http://www.ncbi.nlm.nih.gov/pubmed/25602471

So it’s reasonable to conclude that a number of those unfortunate patients who had not received surgery could develop lung or bone metastasis that are not recognized and don’t receive any treatment or follow-up.

This begs the question as to whether this paper makes any contribution to science. The answer is No.

Studies with questionable heuristic value like this one are certainly in good company. The British Medical Journal, for example, published a study on sword swallowing, which found there were more side effects when the swallower is distracted or swallowing multiple or odd-shaped swords (See: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761150/). It also published a study stating that people with acute appendicitis may feel pain when traveling over speed bumps (See: http://www.bmj.com/content/345/bmj.e8012).

The main problem with the Oda et al paper is that it’s not a joke. Not only did it make it through the peer review process into a good journal, but this paper could become an “Emperor has No Clothes” vehicle for proponents of observation.

So the ethical issue here is one of publication ethics and epistemic integrity. It’s not that a “Duh Study” was published. It’s the fact that it’s being misrepresented as having heuristic value when it’s really Fool’s Gold.

************

Note: This blog was expanded from an initial Letter to the Editor I submitted to THYROID on 3/29/16 entitled “What Heuristic Value?” co-authored by Kenneth Ain, MD. Professor of Medicine and Director, University of Kentucky Thyroid Oncology Program, and Peter Angelos, MD, Ph.D., Professor of Surgery and Chief, Endocrine Surgery, and Associate Director, MacLean Center for Clinical Medical Ethics. The letter was not accepted for publication.

Reproductive Endocrinology

Why Biology is Destiny in a Republican World

March 31, 2016 • By

On March 30, 2016, Donald Trump stated that he would want to “punish women” for seeking termination of their pregnancies (See: http://www.huffingtonpost.com/entry/donald-trump-abortion-punish_us_56fc497fe4b0a06d5804b1ee and http://www.nytimes.com/2016/03/31/us/politics/donald-trump-abortion.html

Within an hour, his campaign quickly tried to edit those comments and qualify that he wishes to, instead, “punish doctors” for helping women end unwanted pregnancies. Here is the statement: https://www.donaldjtrump.com/press-releases/donald-j.-trump-statement-regarding-abortion

Unfortunately, Donald Trump is merely articulating what has been the clear agenda of Republican legislators for years: punishing women by creating a climate in which Roe v. Wade (1973) becomes irrelevant, with the advent of TRAP laws: Targeted Regulation of Abortion Providers.

The result has been a return to the “coat hanger” – as access to safe and legal abortion has disappeared in dozens of states. See: http://www.nytimes.com/2016/03/06/opinion/sunday/the-return-of-the-diy-abortion.html?_r=0

John Oliver recently did a comprehensive piece on TRAP laws, which you can view here: http://www.newsweek.com/john-oliver-last-week-tonight-abortion-law-429026

On March 2, 2016, the Supreme Court began hearing arguments about TRAP laws in Texas in Whole Women’s Health v. Hellerstedt (See: http://www.theatlantic.com/politics/archive/2016/02/us-supreme-court-whole-womens-health-v-hellerstedt/471546/). It will soon decide whether Roe v. Wade has any real meaning anymore when it comes to abortion access. Several editorials about the Texas law appeared earlier this month. See, for example: http://www.usnews.com/opinion/blogs/policy-dose/articles/2016-03-02/supreme-courts-texas-abortion-law-case-is-bad-medicine

and

http://www.chicagotribune.com/news/opinion/zorn/ct-abortion-supreme-court-texas-trap-zorn-perspec-0302-20160301-column.html

TRAP laws don’t just impact adult women; they impact any girl old enough to menstruate who can be raped. Do we really want to force preteen children who are raped and/or victims of incest  to become mothers because they can’t afford to travel to another state? These laws place unfair burdens on poor women and their children by punishing them for being poor and vulnerable by their biology. Contraception is typically inaccessible to many poor women, too, while many school districts even have bans on sex education (See: http://deadstate.org/texas-banned-sex-education-in-schools-now-theres-a-massive-chlamydia-outbreak/).

But the most morally egregious TRAP law was recently passed in Indiana, in which it is now illegal to terminate any pregnancy due to a genetic abnormality. (See: http://www.chicagotribune.com/news/nationworld/midwest/ct-indiana-abortion-ban-genetic-abnormalities-20160324-story.html). This will now force girls and women without means to care for a potentially profoundly disabled child that requires lifelong, complex medical care. But at the same time, the very legislators who support TRAP laws, also support cutting government benefits for the poor.

Many young women probably don’t remember the iconic image of Geraldine Santoro, whose image was the cover story of a 1973 Ms. Magazine. The picture spoke to millions of women trapped by biology and circumstance. Desperate to end her unwanted pregnancy, Santoro and her boyfriend embarked on a DIY procedure, which ended with her bleeding to death alone in a motel room. (See: https://en.wikipedia.org/wiki/Gerri_Santoro). Santoro was not identified until the 1990s, when a film was made of her life (See: http://www.nytimes.com/1995/03/31/movies/film-festival-review-the-woman-behind-a-grisly-photo.html). She died in 1964, and 52 years later, other women living under TRAP laws are at high risk of dying in exactly the same way.

It seems this month was a March to Access.

Reproductive Endocrinology

Mosquitos and Reproductive Ethics

February 29, 2016 • By

It’s a good thing February has an extra day this year. I needed it to ponder the unfolding story of the Zika virus, which earlier this month was declared by WHO to be an international public health emergency. (See: http://www.nytimes.com/2016/02/02/health/zika-virus-world-health-) A good review of this crisis was just published in Newsweek today: http://www.newsweek.com/2016/03/11/zika-microcephaly-connection-brazil-doctors-431427.html

When we first heard about this mosquito-borne virus and microcephaly, it was a tragic pediatric ethics story. It echoes in some ways the birth defects eventually linked to the drug, thalidomide. But the thalidomide births (which did not cause brain damage) led to the question of reproductive rights, and whether women had the right to terminate pregnancies they knew were affected, as they felt a moral obligation to prevent a harmed life. One of the most public cases of a woman desiring to terminate a thalidomide-affected fetus was Sherri Finkbine, who traveled to Sweden to have her abortion. See the 1962 story from the BBC here: (http://news.bbc.co.uk/onthisday/hi/dates/stories/august/26/newsid_3039000/3039322.stm). Finkbine was denied the right to an abortion by the Arizona courts before deciding to go to Sweden.

Now, over 50 years later in Brazil, women are facing the same dilemma from an insidious cause that is not a drug, but a bug. In a Catholic country where abortion is not accessible, women without means are having babies with microcephaly, resulting in severe impairment. A multidisciplinary group of Brazilian experts are now petitioning the supreme court to allow abortions for women who have contracted the virus. (See: http://www.bbc.com/news/health-3543568).  In Columbia, where women with the virus have access to abortion, fewer cases of microcephaly have been seen. (See: http://www.nytimes.com/2016/02/16/world/americas/zika-virus-in-colombia-presents-complicated-choice-about-abortion.html). The Zika virus has also ignited feminist ethics questions with respect to unfair burdens on women solely because of their biological vulnerabilities (See: https://www.bostonglobe.com/ideas/2016/02/07/zika-reproductive-rights-issue/U5HBV4u3J5HPscGUcJHefI/story.html).

Clearly, when poor countries are facing epidemic rates of catastrophic birth outcomes that could be prevented, other distributive justice questions are raised, which has forced even the Catholic Church to reconsider its positions. The Pope has declared that birth control is permissible until Zika is under control. (See: http://www.motherjones.com/mojo/2016/02/pope-francis-zika-abortion-contraception-microcephaly).

Talk about a Leap of Faith on this February 29, 2016.

Uncategorized

Why Flint Should Make You Sick

January 31, 2016 • By

The most dominant ethics story this month is the unfolding public health and pediatric ethics disaster caused by unethical and incompetent actors in Flint, Michigan.

The saga and health consequences of the decision to switch Flint’s water source to the Flint River is nicely outlined in the Time cover story published January 21, 2016: (See http://time.com/4188328/the-poisoning-of-an-american-city/) . If you can’t get past the “pay wall” to “The Poisoning of an American City”, here are other good reviews of the crisis:

http://www.nytimes.com/interactive/2016/01/21/us/flint-lead-water-timeline.html?_r=0

http://www.nytimes.com/2016/01/21/us/flint-michigan-lead-water-crisis.html

http://www.motherjones.com/environment/2016/01/flint-lead-water-crisis-timeline

The consequences of lead poisoning to endocrine development can be explored here, although more research is clearly needed within the pediatric endocrine context: http://www.ncbi.nlm.nih.gov/pubmed/19411819

Flint is an organizational ethics story that became a health disparities story. In this case, shortsighted decisions were motivated by budgets and greed. There was no consideration of potential environmental or health consequences of switching water sources, which is the hallmark of competent decision-making. Such considerations are especially critical when children’s health is at stake, as special protections in public health decision-making need to be in place for our most vulnerable populations.

What makes this a health disparities story is that once the water was switched, the complaints from a poor community were disregarded, as those who became ill from the water were disenfranchised.

This isn’t the first time poor American children have been lead poisoned this century. Researchers were called out in 2001 for exposing poor children to lead in an infamous paint study: (See: http://www.nytimes.com/2001/08/24/health/children/24LEAD.html)

Baltimore has had a particularly shady history of lead exposure in poor communities: http://fivethirtyeight.com/features/baltimores-toxic-legacy-of-lead-paint/

For more on lead poisoning and race, see: http://www.motherjones.com/kevin-drum/2016/01/lead-and-race-flint—and-everywhere-else

Although the Flint water crisis has been compared by others to Hurricane Katrina, this crisis is more comparable to the terrible decisions made in the early 1980s surrounding the public blood supply. In the early days of AIDS, the blood industry decided it was too expensive to screen potential blood donors, which led to the unnecessary spread of HIV/AIDS into the public blood supply, but particularly into the pediatric population. We are still recovering from those decisions. The Executive Summary of the Institute of Medicine Report, HIV and the Blood Supply can be seen here: http://www.ncbi.nlm.nih.gov/books/NBK232406/

Flint echoes many painful health disparities and global health episodes in which members of a disenfranchised community were not heard.

What may be the most instructive about the Flint saga are the moral heroes of the story. (See: http://www.motherjones.com/politics/2016/01/flint-water-crisis-lead-heroes ). Of note is Dr. Mona Hanna-Attisha, who demonstrated moral courage and spoke up on behalf of her vulnerable patients and their families.

Ultimately, this infamous public health disaster we will now always refer to as “Flint” is about sickening business decisions and a failure of accountability.

 

Uncategorized

Editing Ourselves: 2015 and CRISPR

December 31, 2015 • By

The biggest bioethics story of the year was the breakthrough in human genome editing using CRISPR-CAS9. As one bioethicist put it, long-term employment is here to stay for all bioethicists in light of these new, truly slippery slope technologies (See: http://ieet.org/index.php/IEET/more/caplan20151210).

While it’s nice to know that bioethicists will have job security, I’m not sure the bioethics community is comfortable about the reason.

Fears of human genome editing were simmering by Spring 2015, after multiple studies published by various research groups around the world surrounding gene editing using the technology CRISPR-CAS9 (See: http://motherboard.vice.com/read/germline-engineering). In response, there was a call for a moratorium on gene editing of human germ lines because there were concerns that the science was ahead of the ethical implications (See: http://www.nature.com/news/don-t-edit-the-human-germ-line-1.17111 and http://www.sciencemag.org/content/348/6230/36.short).

But it was too late; a Chinese team of researchers published in April 2015 that they had performed such an experiment on human embryos. (See: http://link.springer.com/article/10.1007%2Fs13238-015-0153-5 ).

And then the debates raged regarding the ethical implications:

The year closed with an historic summit on human gene editing held December 1-3, 2015. This summit was comparable  to the 1975 Asilomar conference, in which the scientific community felt that self-regulation about recombinant DNA technology was necessary (See: https://en.wikipedia.org/wiki/Asilomar_Conference_on_Recombinant_DNA).

The International Summit on Human Gene Editing held December 2015 led to moral consensus on three key issues:

  1. Refrain from research and applications that use modified human embryos to establish a pregnancy.
  2. Caution in development of clinical applications until we know more about safety and efficacy, and the risks of inaccurate editing.
  3. Moratorium on ‘germline’ editing — the deletion of a gene prenatally in an effort to erase an inherited disease from an embryo and prevent it from being passed on to future generations.

Here is the position paper:

http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12032015a

See also this summary of the position paper in Nature: http://www.nature.com/news/gene-editing-summit-supports-some-research-in-human-embryos-1.18947

Other summaries of the Summit are here:

A good perspective on the Summit authored by one of the organizers is here:

http://www.nature.com/nature/journal/v528/n7580_supp/full/528S6a.html

Although the Summit concluded with a moratorium on germ line editing, reproductive endocrinologists already use PGD to eliminate genetic diseases, which some argue should be the superior method to deal with genetic disease in which there are some normal embryos (See: https://www.ipscell.com/2015/04/crispr-versus-pgd/). I blogged about PGD in July 2015 (see: http://endocrineethicsblog.org/preimplantation-genetic-diagnosis-safe-sex-in-a-gattacan-world/).

Jumping ahead, what are the basic ethical implications of human gene editing? Well, that’s the problem – we just don’t know. Based on the questions raised by PGD, it’s not just about access issues, “super race” or designer babies, but we could be eliminating “defects” from the genome that are, in fact, attributes, or introducing “attributes” that wind up changing the human condition in unfathomable ways.

Some food for thought with your champagne tonight!

Diabetes

Death, Taxes, Turkey, and ISIS: This Year’s Diabetes Awareness Month

November 30, 2015 • By

This has not been a good month for anyone in the world. But there has been some especially bad news about diabetes this month, too.

On Veteran’s Day, the International Diabetes Federation called upon the G20 world leaders — who were about to meet in Turkey Nov 15-16 — to discuss a sugar tax to help reduce, and pay for the global disease burden of both obesity and diabetes.

Diabetes has now emerged as the biggest “killer disease” globally, surpassing HIV, tuberculosis and malaria combined. (See: http://www.reuters.com/article/2015/11/12/us-health-diabetes-sugar-idUSKCN0T100K20151112#C30Xvj0aGKKIX2MZ.97 and http://www.huffingtonpost.com/entry/diabetes-deaths_5643e784e4b08cda348777bf).

The IDF compared the crisis in diabetes to the global financial crisis of 2008, and pointed out that the global economy is at stake if we cannot get the epidemic under control. Currently 415 million adults globally have diabetes (the largest number of cases are in China), and we spend $673 billion in diabetes care. By 2040, one in every 10 adults in the world are expected to be diabetic, with cases projected to reach 642 million with healthcare spending on diabetes to reach $802 billion.

Then the Paris attacks of 11/13 happened, and no one in Turkey talked about diabetes. And fewer Americans talked about turkey. Instead, the global response to the Paris ISIS attacks dominated all discussions. Once again, the U.S. is faced with debating sending ground troops to fight a war – perhaps even a world war. This time, we’re going to need a lot of troops, and resource allocation is a problem. Our strained, all-volunteer military is exhausted after multiple tours in Iraq and Afghanistan.

Here’s where all this connects.

In the U.S., we don’t have enough fit people to even recruit into the volunteer military because of obesity issues. See: http://www.motherjones.com/mojo/2012/12/most-americans-are-still-too-fat-defend-america

In fact, my first blog was about this problem. See: http://endocrineethicsblog.org/childhood-obesity-and-national-security-widespread-consequences/

The number of ground troops needed from the U.S. to fight ISIS is estimated to be around 50,000 (see: http://philadelphia.cbslocal.com/2015/11/18/former-military-strategist-significant-ground-troops-needed-to-defeat-isis/).

If we need that many, we’re going to have to bring back the draft. (In fact, Russia just did that last month).  It may be that bringing back a draft, along with a sugar tax, would also solve the “diabesity” problem. Our young adults would be forced to get fit. Our older adults would consume less sugary foods, and would even help pay for the war.

Is it ethical to have a draft? At times, it is ethically justified to have a military draft; WWII met that criteria. And maybe, in the face of this heinous threat, now would be a good time to bring it back. Making our young adults fit could not only combat the obesity threat at the same time, but may prolong more lives, even when weighing the risks of putting them in harm’s way.

Not quite the usual Turkey talk in November, but that’s how Diabetes Awareness Month went down in 2015.

Breast Cancer

Boo: Scary New Guidelines for Breast Cancer

October 30, 2015 • By

This year, it’s fitting that Breast Cancer Awareness Month is in October, because just in time for Halloween, diagnosis and treatment of early breast cancer just got scary.

New breast screening guidelines are recommending fewer screenings beginning at age 45 instead of 40, as well as eliminating clinical breast exams (See: http://jama.jamanetwork.com/article.aspx?articleid=2463262 and http://www.huffingtonpost.com/2015/10/19/breast-cancer-screening-guidelines-american-cancer-society_n_8337850.html ).

Meanwhile, there is a growing trend to recommend “doing nothing” for a diagnosis of DCIS when there is no way to predict which early breast cancers will remain indolent, and which will become invasive. (See http://time.com/4057310/breast-cancer-overtreatment/ and http://www.wsj.com/articles/debate-over-early-stage-cancer-to-treat-or-not-to-treat-1445276596 )

These are dramatic shifts that fly in the face of the breast health mantra: “prevention and early detection” as explained to women here: http://preventcancer.org/prevention/preventable-cancers/breast-cancer/breast-cancer-prevention-early-detection/.

Right now, the experts in the breast cancer community sharply disagree about screening guidelines and early breast cancer treatment (See: http://www.nytimes.com/2015/10/29/opinion/why-the-annual-mammogram-matters.html?_r=1).

The Principle of Beneficence in clinical ethics obligates healthcare providers to maximize benefits, while minimizing harms. Early detection and prevention fit these criteria, as there is still a greater balance of benefits than harms in stopping invasive breast cancer before it starts. Meanwhile, leaving biopsy-confirmed breast tumors inside of women, when early treatment is available, could violate the Principle of Non-Maleficence, which, at minimum, obligates healthcare providers not to deny patients a standard treatment when one exists. Those who defend “doing nothing” make the “over treatment” argument, and are concerned about false positives and iatrogenic harms. However, millions of women in countries where early detection and prevention are accessible are alive because of early detection, diagnosis and treatment (See: http://www.nbcnews.com/health/cancer/catching-breast-cancer-early-saves-lives-study-confirms-n439591)

Much Ado About Nothing

Merely watching, or observing the natural history of an untreated disease resembles another study that the public eventually found unethical: The Tuskegee Syphilis Study, in which observation (what is generally meant by “active surveillance” or “watch and wait”) of a known disease was presented as a standard of care to poor African-American patients who were not informed that treatment (when it became available) was an option. (See: http://www.cdc.gov/tuskegee/timeline.htm).

The study led to the formation of codified research ethics guidelines in The Belmont Report, which specifically outlined special protections for vulnerable populations in the Principle of Respect for Persons. (See: http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html )

Yep, I went there.

Proponents of observational (“active surveillance”) protocols really hate it when bioethicists yell “Tuskegee” in a crowded clinic. But unfortunately, I need to go there because that’s where this is going when you factor in the widening gap in healthcare disparities, poor access to genetic screening for BRCA1 and 2 mutations (costs range from $500-4000), and the dozens of barriers to informed consent that include low literacy, low numeracy, and non-English speaking patients. Few know about “Tuskegee India” – a U.S. funded cervical cancer study in the late 1990s that repeated Tuskegee’s design flaws. Here, over 250 vulnerable women in unscreened control groups — without proper consent — died from cervical cancer in a study designed to look at whether screening made a difference — when we already knew that it did. See: http://www.al.com/opinion/index.ssf/2015/06/india_cervical_cancer_testing.html

If you’re going to change breast cancer screening guidelines, it must be balanced with improved access. Since so many vulnerable populations do not have access to women’s healthcare, it’s ethically problematic to change guidelines to avoid over-diagnosis and over-treatment when so much under-treatment exists. At least 15 million U.S. women have no healthcare access at all (not including undocumented women), while breast cancer continues to affect African American women disproportionately due to both initial access and follow up. See:

The ACS Guidelines even admit: In the United States, barriers to access continue to exist among low-income or uninsured women, those without a usual source of care, or those residing in rural counties.

Telling women to skip their screenings (which include some 5-10% of women in the general population who do not know they are BRCA1 or 2 carriers) is ethically problematic. Telling women with biopsy-confirmed breast tumors that observation is a “reasonable treatment alternative”, when there is not enough evidence to conclude that, is also ethically problematic unless women are told what the risk of doing nothing entails. In our unequal healthcare system, where coverage is not uniform, informed consent my be insufficient, and many are lost to follow-up, these new guidelines are…well… just scary.