Browsing Articles Written by

Dr. M Sara Rosenthal


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 . If you can’t get past the “pay wall” to “The Poisoning of an American City”, here are other good reviews of the crisis:

The consequences of lead poisoning to endocrine development can be explored here, although more research is clearly needed within the pediatric endocrine context:

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:

Baltimore has had a particularly shady history of lead exposure in poor communities:

For more on lead poisoning and race, see:—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:

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: ). 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.



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:

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: 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: and

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: ).

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:

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:

See also this summary of the position paper in Nature:

Other summaries of the Summit are here:

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

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: I blogged about PGD in July 2015 (see:

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!


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: and

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:

In fact, my first blog was about this problem. See:

The number of ground troops needed from the U.S. to fight ISIS is estimated to be around 50,000 (see:

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: and ).

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 and )

These are dramatic shifts that fly in the face of the breast health mantra: “prevention and early detection” as explained to women here:

Right now, the experts in the breast cancer community sharply disagree about screening guidelines and early breast cancer treatment (See:

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:

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:

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: )

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:

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.


Reproductive Endocrinology

Planned Attack on Women’s Reproductive Healthcare

September 30, 2015 • By

Yesterday, Cecile Richards, president of the Planned Parenthood Federation, testified before Congress regarding the now-infamous doctored videos manufactured by anti-choice activists. (See:  and

You can watch the entire testimony here:

Despite the facts, Republican members of the House Oversight and Government Reform Committee continued their line of questioning as if the videos were factual. Their questioning also revealed such alarming ignorance of women’s healthcare, and the organizational structure and funding of Planned Parenthood, that one wonders whether they truly demonstrated an adequate level of decision-making capacity — a basic standard we demand from patients for informed decisions, which requires Understanding, Appreciation and Rationality. Most of the questions asked of Ms. Richards did not meet this standard, including one member asking her if she believed in “selling baby parts”— phrasing that demonstrates stunning levels of medical illiteracy and ignorance of the laws surrounding fetal tissue research (see:

The Chairman of the committee belligerently presented an inaccurate slide from a pro-life organization, claiming it came from Planned Parenthood (see: When Ms. Richards politely noted the source of the slide was from “Americans United for Life,” an anti-choice lobby, and assured the Chairman it was not accurate, he yielded the floor.

Any provider of women’s healthcare should be alarmed that funding for critical reproductive healthcare services are being debated by Congressional representatives who don’t seem to meet the same standards of decision-making capacity we would demand of patients or their surrogates. They do not understand or appreciate the facts of how Planned Parenthood is funded; what fetal tissue research is; or even, at minimum, that the videos in question are not authentic.  Further, they do not demonstrate rationality — an ability to reason with the information provided to them by Planned Parenthood.

The only thing that was clear about this “hearing” was that the Republicans were unable to listen.



Lessons About Death and Dying on 9/11

September 11, 2015 • By

On this 14th Anniversary of 9/11, healthcare providers of all disciplines should remember the lessons about death and dying on 9/11, elucidated in my 2013 paper: “The End-of-Life Experiences of 9/11 Civilians: Death and Dying in the World Trade Center.” (See:

The powerful lesson from those trapped and dying in the World Trade Center 14 years ago this morning was truth-telling. These tragic civilians still had decisions to make, and needed the truth so they could make decisions about where to die and how to die. In the North Tower, civilians who called emergency operators by dialing 9-1-1 were told: “Stay where you are”, which was a high-rise fire script that was completely inappropriate for what was unfolding on impact floors. Trapped civilians — who realized they were at the end of life —  made other decisions: they exercised their right to palliative approaches to an imminent death by breaking windows (when they were told not to) and jumping. Some made the choice to call loved ones and guarantee that their coordinates and circumstances were known. These were short calls, as time was short, with a consistent message: they told a loved one that they were trapped in a fire; they couldn’t get out; and they loved them.  Voicemails later became critical forensic evidence in deaths that were classified as homicides.

In the South Tower, hit second, but first to collapse, civilians had a close-up view to the horrors unfolding in the North Tower, and perceived their lives were threatened in the 16 minutes prior to their own tower being hit. Despite hearing an intercom message that their building “was secure” and to “return to your offices”, many made autonomous choices to self-evacuate and leave the building, saving themselves from being trapped on impact floors. Some made a different choice in those 16 minutes: they made “reassurance calls” to family members with a consistent message that they were in the “other building” (Tower 2), and they were safe.  Some of those calls delayed evacuation, but illustrate that connection and communication was a priority. Those in the South Tower who were trapped also made calls to 9-1-1 operators demanding to know whether firefighters would get to them in time as their environment deteriorated, but they were denied proper end-of-life dialogues. Instead of being asked by a skilled responder: “Is there someone I can call for you?” when callers explained they could no longer breathe, they were asked to spell their names, and even transferred or put on hold. This interfered with critical closure calls many would have made to family members instead of dying on hold with a 9-1-1 operator. Some callers simply called family and died on the phone with their loved ones. Several of these calls are available in the public record: (
and )

The lessons learned about death and dying on this terrible morning on September 11, 2001, are not new: they reinforce what end of life experts have known for over 40 years (See: Kubler-Ross, E., 1969 On Death and Dying. New York: Macmillan). People at the end of life want the truth so they can make choices about how to die and where to die.

In recent years, endocrinologists have found themselves in the position of needing to have end-of-life discussions. Especially those who deal with end-stage renal patients who are not transplant candidates, or patients with devastating diagnoses such as anaplastic thyroid cancer (See If you can’t tell the truth, reach out to a colleague who is expert in end-of-life dialogues so you can allow patients to make critical decisions. Trapped civilians who were in the towers teach us that even in the most imminent and dire circumstances, we can still make a myriad of end-of life decisions so long as we are told the truth.


The Aftermath of Hurricane Katrina: A Disaster for an ENT Surgeon

September 1, 2015 • By

Imagine learning that the surgeon who performed the total thyroidectomy on your thyroid cancer patient was being charged with homicide for deliberately euthanizing ICU patients ?

Ten years ago today (September 1, 2005), one ENT surgeon, Anna Pou, found herself in the eye of the storm’s crippling aftermath, and instead of relying on her surgical skills, was thrust into the role of having to make disaster ethics triage decisions for a group of very sick ICU patients – most of whom were ventilator-dependent, who had been stranded in Memorial hospital in the wake of Hurricane Katrina.

Is this part of the training of an ENT surgeon? No. And that proved disastrous for Anna Pou, who had to endure, along with two of her colleagues, charges of homicide consequent to evidence of euthanasia. (She was never indicted, and the charges were eventually dropped.)

Here is the 60 Minutes clip which originally aired 9/24/06 chronicling the ordeal of Dr. Pou and her nurse colleagues:

In 2013, Sheri Fink’s Five Days at Memorial (See:, which won the 2013 Pulitzer Prize, chronicled the events that went on at Memorial Hospital during the catastrophic flooding following Hurricane Katrina, in which 19th Century medicine needed to be practiced at the turn of the 21st Century.

Many of the same challenges played out again during Hurricane Sandy: (See, for example: and this:

What these events teach us is that Disaster Ethics has to be taught in medical schools and residency programs. We’re living in a time of climate change, a future of more powerful and frequent hurricanes (See:, combined with vulnerable infrastructures (see:

Every healthcare provider in training or practice today is at risk of being in the eye of a storm as weather will only get worse, and vulnerable populations will only increase. Weather is predicted to get far more severe, and hospitals will need to ride out hurricanes, flooding, tornadoes, blizzards, and ice storms. All of these weather systems can and wreak havoc on aging infrastructures, and knock out power, but the power grid itself is vulnerable even in the absence of extreme weather (see: and



Lessons from Hurricane Katrina: Diabetes in the Population Below See-Level

August 29, 2015 • By

Today marks the 10th Anniversary of Hurricane Katrina, which revealed alarming data from an “accidental” 2005 diabetes care study funded by “Mother Nature” in a state that ranked at the time 48th in levels of health insurance, 45th in public health, and 50th in overall health (See:

This event revealed clear health disparities to the average television viewer. The incidence and co-morbidity of diabetes and/or diabetes complications in the population that stayed behind — the lower income and largely African-American community — overwhelmed the ability of public health agencies to respond in this national emergency (See also: and )

Diabetes complications interfered with evacuation, rescue for those who survived, and appropriate resources for evacuees with limited supplies. Some authors liken Katrina to the infamous distributive justice tale of the Titanic, in that there were clearly “not enough lifeboats” for diabetes patients in “steerage class”.

Hurricane Katrina put the health effects of poverty and race in plain view, although the health disparities in the incidence and management of Type 2 diabetes had long been documented at the time of the storm (See:

  • African-Americans are twice as likely as Caucasians to have diabetes.
  • African-Americans suffer greater diabetes-related complications.
  • Uninsured diabetes patients in 2005 had a 25% greater risk of premature death.
  • The percentage of uninsured African-Americans in 2005 was 73% greater than in the Caucasian community.
  • African-American diabetes patients in 2005 were less likely to have their A1C measured.
  • Usual care for African-American diabetes patients in 2005 failed to meet published diabetes care guidelines.

Hurricane Katrina taught us that chronic disease management is a critical public health need in a disaster — on par with infection control. Stockpiling supplies for diabetes care should now be part of Disaster Planning.

In 2012, diabetes patients with end-stage renal disease caught in Hurricane Sandy were at risk again. (See:

How many hurricanes does it take to get disaster diabetes care planning right? We’re not there yet, but we do know that diabetes and poverty always spell disaster for stranded vulnerable populations.


Why Hillary Clinton’s Thyroid Needs Healthcare Reform

August 7, 2015 • By

As a bioethicist, I’m disturbed that the person highly likely to be the next President of the United States is receiving substandard treatment for hypothyroidism. Hillary Clinton’s health records were just released to the public, which was not a HIPAA violation but standard protocol for Presidential candidates as health and fitness for office are released to the voting public.

Unfortunately, it was revealed that Hillary Clinton is not being properly treated for hypothyroidism. Instead of being prescribed the standard of care — levothyroxine sodium — she is being prescribed desiccated thyroid hormone — which is an antiquated and less stable form of thyroid hormone replacement, as any board-certified endocrinologist or physician with demonstrable training knows. Here’s the report from the Daily Mail that makes public her doctor’s report:

Levothyroxine sodium has been the standard of care for many years, so it is not easily explained why Ms. Clinton’s internal medicine physician would not follow the standard of care. The most recent clinical practice guidelines from both the American Association of Clinical Endocrinologists (AACE) and the American Thyroid Association (ATA), strongly recommend against the use of desiccated thyroid hormone. See Recommendations 22.1 and 22.4 in the joint ATA/AACE “Clinical Practice Guidelines for Hypothyroidism” ( and Recommendations 1a and 12 in the ATA “Guidelines for the treatment of hypothyroidism” ( )

The site, “Quackwatch”, managed by Dr. Steven Barrett, even has a warning about physicians who prescribe desiccated thyroid hormone:

There are only two reasons why a physician would prescribe desiccated thyroid hormone to a hypothyroid patient in the year 2015 (as opposed to the year 1915):

  1. The physician is not aware of the standard of care, and offered it as an option. Although it’s true that physicians with no special training or board certification in endocrinology manage many hypothyroid patients, clinical practice guidelines put out by specialty organizations exist for the purpose of educating and updating these colleagues about the acceptable and recommended standards of care. Internal medicine practitioners, such as Ms. Clinton’s physician, have a legal and ethical duty to stay up to date and proficient in standards of care for multiple common conditions. Since hypothyroidism is one of the most common conditions seen by internal medicine practitioners, prescribing a medication that is below the standard of care – particularly to the former Secretary of State and potentially future POTUS, is ethically concerning. If Ms. Clinton was offered desiccated thyroid hormone as an equal alternative to levothyroxine – either by her internist or a different physician — then she was unable to provide informed consent.
  2. The patient has declined the standard of care. Many hypothyroid patients search the Internet or popular health books about treatments. Unfortunately, purveyors of misleading information that desiccated thyroid hormone is “natural” and therefore better for you, is a common false message patients will find. Many physicians spend considerable effort to educate (or de-program) hypothyroid patients that desiccated thyroid hormone is below the standard of care, but some patients insist on it against medical advice. Or, a patient may refuse to switch to the standard of care if desiccated thyroid hormone was prescribed by a different physician. In these cases, it is ethically permissible to prescribe (or renew) desiccated thyroid hormone because it is, at least, better than nothing. Not providing thyroid hormone replacement would lead to severe hypothyroidism, which could mean loss of decision-making capacity in the short term, and myxedema coma in the long term.

This situation leads to wider, unintended consequences for thousands of hypothyroid patients, which I call the “Oprah Problem”. Oprah Winfrey’s 2007 diagnosis of what was probably Hashimoto’s thyroiditis led to her promoting non-standard therapies on her show, endorsed by factitious experts with no training in thyroidology (See: Patients assume that women with the power and stature of Oprah Winfrey or Hillary Clinton must be receiving the very best care in the United States and may request the same non-standard therapies. This results in pointless harm. Unfortunately fame is often a barrier to good care for reasons having to do with “VIP Syndrome” – when physicians become star-struck, and are reluctant to refer their famous patients to more experienced physicians.

Considering Hillary Clinton’s long dedication to American healthcare, she deserves, at least, the prevailing standard of care, not a level of care that is so far below the community standard.


Hey, Hey, LBJ: How many Seniors did you Save Today?

July 31, 2015 • By

If you’re an endocrinologist who takes care of seniors with diabetes, you should say “Thank You!” to Lyndon B. Johnson.

Yesterday marked the 50th anniversary of Medicare (see: And while the politics and questions about this program continue (see:, it marked a healthcare ethics milestone in the United States.

Medicare has had an especially profound impact on ethical care for people with diabetes, and end-stage-renal disease (see:

But Oh — The Times They Are A-Changin’…

When Medicare was signed into law on July 30, 1965, just 1.2% of the population had diabetes, which translated then into 2.39 million Americans. In 2014, the CDC reported that 29.1 million Americans (9.3% of the population) have diabetes, but of those, 8.1 million remain undiagnosed (see: You can view the growth in diabetes prevalence from 1958-2013 here:

The sharp increase in diabetes was likely never foreseen, but we now know how much this is tied to obesity and our toxic diet, particularly the aggressive marketing of sugary drinks. (

Countless people with diabetes may not be diagnosed until they have access to primary care and health coverage, which is why last month’s SCOTUS ruling on the Affordable Care Act is so important. (

It was also reported yesterday that only 1 in 3 seniors are actually well controlled, and some of these reasons may have to do with continuing health disparities.

One thing is certain: LBJ did the right thing 50 years ago. And your patients are still benefiting.