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Health

Publishing Negative Research Results

Ben Goldacre, in the Guardian this weekend, noticed the range of headlines on health and health risks that are to be found in the media. He mentions, among others, the rise of ‘manorexia’, the failure of water to induce weight loss and the dangers of antibiotics to prevent premature birth. I found a couple more: It turns out that dark chocolate can reduce the risk of heart attacks, vegetable rich diets and in particular vegetables like broccoli reduce the chance of heart disease and stroke and turmeric, the spice that makes curries yellow, can reduce the size of hemorrhagic stroke.

It’s quite striking what research is done!

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A Nasty Dilemma for NICE

After a prolonged disagreement with patient groups, the NHS’s funding guidance body, NICE, has approved the £10,000-an-eye blindness treatment, Lucentis. The drug has been shown to halt the progression of wet age-related macular degeneration (AMD), the most common cause of blindness in developed countries. But as the BBC  note, in approving it, NICE may have unwittingly deprived the NHS of a much cheaper alternative.

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When the heart stops: harvesting organs from the newly (nearly) dead

In the New England Journal of Medicine yesterday, doctors from Denver reported on three controversial cases of heart transplantation from newborn infants. These cases are striking for several reasons. They were examples of so-called ‘donation after cardiac death’ (DCD), an increasingly frequent source of organs for transplantation, but done very rarely in newborns. They are controversial because the transplanted organs were hearts that were ‘restarted’ in recipients after they had stopped in the donor. Transplant surgeons waited only a relatively short period after the donor’s heart had stopped (75 seconds) before starting the organ retrieval process. These transplants raise serious questions about the diagnosis and definition of death.

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Cold and Calculating NICE

Yesterday’s Daily Mail online contains an opinion piece bemoaning the decision by NICE – the UK body responsible for rationing healthcare resources – to decline funding for four new treatments for Kidney Cancer. The Mail complains:

…what does NICE offer by way of explanation? A cold, calculating statement that, while the drugs work for many of those with advanced kidney cancer, they are not ‘cost-effective’.

What a clinical way to assess whether a person should be afforded precious extra months and years of life, or consigned to a ‘death sentence’.

I don’t want to defend NICE’s decision in this particular case, but the Mail’s attack on NICE’s "clinical" decision-making process is clearly unjustified.

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The point of death

The Guardian yesterday reported the death of the man who had been so tragically shot in Antigua, with his wife, three weeks after their wedding. It began like this:

"Ben Mullany, the newlywed who was shot on honeymoon in Antigua in an attack that killed his wife, Catherine, died in hospital in Wales yesterday after his life support machine was switched off.  The 31-year-old trainee physiotherapist, who had suffered a fractured skull and had a bullet lodged in the back of his head, was flown back to Britain while in a coma on Saturday. Tests carried out when his condition stabilised after the 24-hour journey established he was brain dead." 

This is a familiar way of describing such happenings, even among clinical professionals.   Brain death is pronounced, so the life support machine is switched off, and the patient dies.   The clear implication is that brain death is not death.  The machine is still keeping the patient alive, and it is switching off the machine that causes real death. 

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Testing alternative therapies

The journal Science is today reporting on a controversial plan by the US National Institute of Mental Health (NIMH) to test an alternative treatment for autism on children. The treatment, known as chelation therapy, involves the use of drugs that remove heavy metals from the blood. It’s based on a the theory – unsupported by conventional science – that mercury in vaccines triggers autism.

Chelation therapy is widely used, but its benefits and effects are not well understood. The NIMH have therefore argued that there is a "public health imperative" to test the drug. But opponents claim that any such study would be unethical, since the quality of the trial is likely to be poor, and any results – especially negative ones – would be unlikely to alter the behaviour of parents who support the therapy.

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Paying to top up NHS treatment

The BBC has this week published a story on co-payment in the UK’s National Health Service. Sue Matthews, a Buckinghamshire woman with terminal bowel cancer, would like to top up her NHS care by paying for a £30,000 course of cetuximab – a drug which could extend her life, but which is not funded by her NHS trust. However, if she does so, she may also have to pick up the tab for her standard NHS treatment. That’s because the NHS guidelines advise against allowing such co-payments: they require that a given instance of treatment be either fully privately funded, or fully publicly funded.

Should co-payments be banned?

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Sport, Sudden Cardiac Death and Liberty

Sport, like life, is dangerous. Several fit young footballers have died of sudden unexpected heart attacks. Doctors are now calling for mandatory testing using ECGs of all athletes. Italy has been pursuing mandatory testing for 25 years. This has revealed over 5% have some abnormality. Some people have congenital heart rhythm abnormalities which place them at high risk of sudden heart attack during or after sport. The call for mandatory testing is a sensible one. The interesting question is what is to be done with the results.

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When autonomy trumps sense: the costs of refusal to allow withdrawal of life support.

In Canada this week, an 84 year old man died after 9 months of treatment
in an intensive care unit. He had severe brain damage and multi-organ
failure, but his family sought a legal injunction to prevent doctors in
the intensive care unit from withdrawing life-support. Over the course
of his long intensive care stay, intensive care beds at a major trauma
centre were closed so that nurses could used instead to support his
care, and three doctors resigned from the hospital in protest at being
required to provide what they felt was ‘unethical’ treatment.

Read More »When autonomy trumps sense: the costs of refusal to allow withdrawal of life support.