The Sports Gene?

Born to Run? Little Ones Get Test for Sports Gene:

When Donna Campiglia learned recently that a genetic test might be able to determine which sports suit the talents of her 2 ½-year-old son, Noah, she instantly said, Where can I get it and how much does it cost?

“I could see how some people might think the test would pigeonhole your child into doing fewer sports or being exposed to fewer things, but I still think it’s good to match them with the right activity,” Ms. Campiglia, 36, said as she watched a toddler class at Boulder Indoor Soccer in which Noah struggled to take direction from the coach between juice and potty breaks.

“I think it would prevent a lot of parental frustration,” she said.

In health-conscious, sports-oriented Boulder, Atlas Sports Genetics is playing into the obsessions of parents by offering a $149 test that aims to predict a child’s natural athletic strengths. The process is simple. Swab inside the child’s cheek and along the gums to collect DNA and return it to a lab for analysis of ACTN3, one gene among more than 20,000 in the human genome.

The test’s goal is to determine whether a person would be best at speed and power sports like sprinting or football, or endurance sports like distance running, or a combination of the two. A 2003 study discovered the link between ACTN3 and those athletic abilities.

The whole thing seems like a money-making scam to me. I say scam because the entire concept discounts the notions of practice, a work ethic, and intelligence in athletics. Except for certain endeavors, like weightlifting perhaps, raw athletic ability will only get an athlete so far. Beyond that, other factors come into play to determine success. I worry that children with "good" results will face even more pressure from their sports-crazed parents to perform up to expectations.

Experts Question Placebo Pill for Children

Just came across an interesting article in the NYTimes: Experts Question Placebo Pill for Children. I have many times wondered this myself: if placebos are so effective, why do we not use them as benign medicines in specific situations? I understand the fears of conditioning, where families start to turn to placebos for every minor ache, but that's better than using old antibiotics or other medications in my opinion. How did this idea arise?

Jennifer Buettner was taking care of her young niece when the idea struck her. The child had a nagging case of hypochondria, and Ms. Buettner’s mother-in-law, a nurse, instructed her to give the girl a Motrin tablet.

“She told me it was the most benign thing I could give,” Ms. Buettner said. “I thought, why give her any drug? Why not give her a placebo?”

Studies have repeatedly shown that placebos can produce improvements for many problems like depression, pain and high blood pressure, and Ms. Buettner reasoned that she could harness the placebo effect to help her niece. She sent her husband to the drugstore to buy placebo pills. When he came back empty handed, she said, “It was one of those ‘aha!’ moments when everything just clicks.”

Ms. Buettner, 40, who lives in Severna Park, Md., with her husband, 7-month-old son and 22-month-old twins, envisioned a children’s placebo tablet that would empower parents to do something tangible for minor ills and reduce the unnecessary use of antibiotics and other medicines.

With the help of her husband, Dennis, she founded a placebo company, and, without a hint of irony, named it Efficacy Brands. Its chewable, cherry-flavored dextrose tablets, Obecalp, for placebo spelled backward, goes on sale on June 1 at the Efficacy Brands Web site. Bottles of 50 tablets will sell for $5.95. The Buettners have plans for a liquid version, too.

Of course, there are critics:

But some experts question the premise behind the tablets. “Placebos are unpredictable,” said Dr. Howard Brody, a medical ethicist and family physician at the University of Texas Medical Branch at Galveston. “Each and every time you give a placebo you see a dramatic response among some people and no response in others.”

He added that there was no way to predict who would respond.

“The idea that we can use a placebo as a general treatment method,” Dr. Brody said, “strikes me as inappropriate.”

Still, later in the piece, even Dr. Brody admits that the product will likely be quite popular. And why not? We already do many actions to treat things which in reality have no true efficacy. Why not formalize the practice? I think if this catches on, pediatricians should simply address it with parents directly, and tell them when it is appropriate to use placebos and when they must bring their child in to see a physician.


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Rent-A-Womb: The Exploitation of India's Poor

Reading "India Nurtures Business of Surrogate Motherhood," I couldn't help but feel a chill run down my spine. The article describes the booming business of Western couples who are unable to reproduce naturally paying surrogate mothers in India to carry fetuses to term. The proprietors of the businesses in India try to put a positive spin on the story, extolling the financial benefits to the women. And, truth be told, the practice does produce a significant amount of income for these women. However, what I found to be truly ridiculous was the following assertion:

“Surrogates do it to give their children a better education, to buy a home, to start up a small business, a shop,” Dr. Kadam said. “This is as much money as they could earn in maybe three years. I really don’t think that this is exploiting the women. I feel it is two people who are helping out each other.”

To help each other?! If these women are truly so generous, I wonder how many of them would sign up for this task on a voluntary basis. That's right: zero. This is obviously all about the money. To try to frame it in any other way is dishonest.

The framing of the practice does matter a lot to how the enterprise is perceived. Even as the piece praises the payoff to the women, the language belies the dehumanizing commercialization of this practice:

Commercial surrogacy, which is banned in some states and some European countries, was legalized in India in 2002. The cost comes to about $25,000, roughly a third of the typical price in the United States. That includes the medical procedures; payment to the surrogate mother, which is often, but not always, done through the clinic; plus air tickets and hotels for two trips to India (one for the fertilization and a second to collect the baby).

Collect the baby? I know this is semantics, but the word 'collect' objectifies the baby. Think about it: you collect your baggage from baggage claim, you collect coins, you call collect. No one collects humans. Well, until now.

Another troubling aspect is the nature of the transaction. Rich Westerners are basically preying on these women's financial situation. Such poverty is implicated in other exploitative practices such as prostitution or substandard working environments. How is this any different? Even if the women are cared for now, what is to prevent unscrupulous providers from entering the market and truly exploiting the women? The whole system seems ripe for abuse.

I suppose this argument is a bit strange, considering that I have previously described a market for organ donations. However, in that post, my implicit assumption was that all sides had relatively equal socioeconomic standing and information. This case differs in that these women are clearly not on the same footing as their benefactors in either resources or education. While I hope some good will come of this arrangement, I fear that the moral hazard is too great to let such a practice continue.

The Return of Paternalism?

Paternalism is the notion of doctors unilaterally acting on the patient's behalf. It follows in that "Father Knows Best"-type of tradition (hence, the word). In recent years though, medical ethics has veered away from the traditional paternal role of the physician towards one of neutral advisor. This new ethic placed patient's autonomy as the paramount ideal. Patients were supposed to make decisions for their own care after being presented with the options in an unbiased manner by their physicians. The physician-as-agent was supposed to merely standby and execute the patient's decision. They could offer advice if asked, but had to be careful not to advocate too forcefully, lest they violate the norm of autonomy.

Of course, most patients who are not well-versed in the issues involved still rely on their doctor's assistance in making that ultimate decision. New research in psychology and behavioral economic shows that perhaps patients do in some cases need this "nudge" in the right direction. However, as the article notes, if one cannot trust the public to act in their own interests after even a "nudge," why not do more?

Many of the suggestions in “Nudge” seem like good ideas, and even, as with “Save More Tomorrow,” practical ones. The whole project, though, as Thaler and Sunstein acknowledge, raises some pretty awkward questions. If the “nudgee” can’t be depended on to recognize his own best interests, why stop at a nudge? Why not offer a “push,” or perhaps even a “shove”? And if people can’t be trusted to make the right choices for themselves how can they possibly be trusted to make the right decisions for the rest of us?

But, therein lies the problem: if doctors push, we risk the pendulum swinging too far back towards paternalism. It seems that there is a real dilemma brewing between the necessity of paternalism and the ideal of autonomy. Modern medicine so far does not seem to have a palatable answer.

The Perils of Organ Donation

Organ donation is clearly an area fraught with ethical dilemmas. A recent story has shed more light on the differing incentives various actors face in the organ donation decision. The story concerns a surgeon who has been accused of inappropriately prescribing medications in order to hasten a donor's death so that the organs harvested would be more viable. At first glance, it seems that the surgeon prescribed medications to ease the man's suffering as he was removed from a ventilator. However, the article goes on to note that the transplant surgeon's presence in the room violated protocol, and that while administering the medications...

According to a police interview with Jennifer Endsley, a nurse, the transplant team, including Dr. Roozrokh, stayed in the room during the removal of the ventilator and gave orders for medication, something that would violate donation protocol. Ms. Endsley, who stayed to watch because she had never participated in this type of procedure, also told the police that Dr. Roozrokh asked an intensive care nurse to administer more “candy” — meaning drugs — after Mr. Navarro did not die immediately after his ventilator was removed.

Sadly, I am more inclined to believe the nurse's version of events. It's sometimes sad to think how technology has given us this great power to save human lives, yet somehow, the entire process almost ends up being almost dehumanizing. I remember observing a liver transplant procedure and being in awe that I was seeing the inside of someone's body with this giant cavity where the liver once was, yet simultaneously, somehow detaching this from the person that lay beneath the drapes. Actually, viewing a harvest was more striking. When we first met the donor, she was in the neuro ICU, brain dead, but her heart was still beating. We went into the OR, draped her, prepped, and soon made an incision and began the harvest. Only after about an hour into it did I realize her heart had stopped beating. A necessary step, yet it seems strange that no one really gave much pause to acknowledge this event. I do not claim that all transplant surgeons / staff are like this, but I do recall having this distinct feeling as I watched the procedures and how the transplant team functioned. I think the rigors of being involved in transplant surgery forces one to compartmentalize and focus so narrowly on the harvest and transplant that one may lose sight of the humanity underneath it all.


Think there's a better way? Read about some more views on organ donation.

A Few Interesting Stories

Whew! Done with Step 1! I've enjoyed a few days off, but it's back to the wards tomorrow, specifically the psych wards. I don't have anything in particular to discuss today, so here's a smattering of links with interesting stories:

When a murderer becomes a medical student - a medical school in Stockholm is faced with a dilemma over what to do when a convicted murderer who has served his time is found to be in the student body.

Do statins really prolong a patient's life? - an interesting look at the issue of how to use a drug for a disease versus as prophylaxis.

Who really gets MRSA? - As reports of a new strain of MRSA among homosexual men appeared, the article notes another group that also has a high incidence of such infections.

Hoarseness on the political trail - Find out what the candidates do in their attempts to not lose their voice while being a "voice for the people."

Seven Common Medical Myths - Haha, I must admit, I have held at least 4 of these.

Does a surgeon's gender matter? - Wow, I never would have considered to research this, but it is something to ponder, especially in gender-based operations (ex. mastectomies, prostate surgery)

Organ Donation Update

Following up on my ground-breaking editorial on organ donation, the NYTimes has recently published two related articles:

• The Moral Institution is written by well-known psychologist Steven Pinker and discusses the underpinnings of morality in general.
  
  
• Economists Dissect the "Yuck" Factor discusses how economists and moralists view the idea of a market for organs.

Check 'em out and remember: you heard the idea for an organ donation market here first!


Want more? Check out how med school affects how med students speak, or Democractic Candidate Healthcare Proposals.