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Rural Health Disparities and Telemedicine

photograph of surgery performed with help of teleprescence robot

Rural America has been struggling from a lack of hospitals and physicians at an alarming rate. In the past decade, ER patients in rural communities have increased by 60% and hospitals in those locations have decreased by 15%. A potential solution to the lack of health care providers is to consider telemedicine as an option for these rural locations. Telemedicine is a remote care center which provides hospitals, clinics, or even individuals with direct access to a physician. One such company that provides this service is Avera eCARE. At Avera eCARE, doctors work out of high-tech cubicles, dressed in scrubs to look the part, but never actually physically touching or seeing their patients. Instead, they use a high-resolution camera and microphone to work with their patients and nurses or healthcare professionals at remote locations.

Dr. Brian Skow is an example of a physician who works from one of the Avera eCARE centers that provides remote emergency care for 179 hospitals across the nation. Skow was called in when a comatose, unresponsive patient came into the emergency room in rural Montana with only nurses on staff. Skow remotely instructed the nurse how to incubate the patient – inserting a tube into the patient’s throat in order to get her onto a ventilator. Without his help, this patient would have most likely died from lack of oxygen.

“If anything defines the growing health gap between rural and urban America,” The Washington Post claims, “it’s the rise of emergency telemedicine in the poorest, sickest, and most remote parts of the country, where the choice is increasingly to have a doctor on screen or no doctor at all.” And Dr. Skow’s situation is a perfect example. He watched as 5 people performed the procedure, all with careful instruction and encouragement from his remote location. To compare this to his hospital at Sioux Falls, he has to compete with an emergency physician, trauma surgeon, cardiologist, anesthesiologist, a team of 20 residents, ER nurses, and paramedics to be at the bedside. This has meant that each month telemedicine can help cardiac episodes, traumatic injuries, overdoses, and burns at a rate that is much higher than before.

There are a number of benefits generated by the move to such a system. Telemedicine helps hospitals retain doctors and recruit them because it allows for time off- and on-site support. Many critical-access hospitals are struggling to find even a single doctor or can’t keep physicians long. This technology offers the option for the nurses and physician assistants to call in for immediate health care suggestions. Another benefit is that hospitals are able to treat more patients with more intense conditions than before, as the technology allows hospitals to treat patients without needing to immediately transfer them. These transfers increase the time in which the patient suffers, and for most of these cases, every second counts. Apart from pain and outcome, transferring also greatly increase billing charges for patients. Even hospitals benefit by treating more cases and thus generating more profit.

Despite these advantages, there are still many limitations. Telemedicine costs approximately $70,000 monthly and $170,000 to install. Hospitals have to face a difficult decision in choosing between installing this technology or investing money on other life-saving machines like MRI and CAT scans.

Critics also worry that telemedicine takes the humanity out of patient-physician relationship. Instead of physically being with the patient, that crucial interaction is separated by a screen and thousands of miles. This reality can affect treatment in ways that are unexpected. Especially in remote communities, it is very common for the nursing staff to know the patient personally, but for the virtual doctor, the patient can become “less human.” Doctor Kelly Rhone, describes this phenomenon as she watched nurses from North Dakota perform CPR on a patient for over 10 minutes. One of the worst things that the remote doctor can do, Rhone argues, is withdraw care too quickly. Even when a patient has passed, it’s important for the medical staff in the room to acknowledge the situation in their own time. This obligation may even extend to being present with grieving family members.

It is important to consider then, if remote care is an adequate substitute and can offer sufficient support for the human element to medicine. Perception can play a major role in diagnosis, and if doctors aren’t seeing their patients in the same way, they will treat them differently. It may be more likely for doctors to withdraw care or save resources, compared to situations where they are with them in person.

There are also some challenges when it comes to telemedicine being used directly in people’s homes. There are apps which can help patients connect with a doctor via Facetime, text messages, and phone calls. There are some benefits to this option. For busy parents and working folk, this is a quick and easy solution to getting better fast. Some people live an hour or more from the nearest health clinic, and so to be able to describe their symptoms over the phone and get their medicine prescribed within minutes is a great benefit. However, there is also the increased risk of misdiagnosis. It can be easy to miss symptoms of larger health problems – when chest discomfort isn’t just a strained muscle, but an early sign of a heart attack, for example. In this way, reliance on telemedicine can increase risk to patients.

There is a clear injustice in our health care services in the United States for rural areas and urban locations. Telemedicine is one option for those who are suffering from lack of adequate healthcare. It increases virtual staff and gives current staff direct access to help for their situations. With the rising trend toward virtual telemedicine, we must consider what cost to patient health we are willing to accept for increased efficiency.

Walgreens and the Conscience Clause

Earlier this month a woman in Arizona, Nicole Arteaga, tried to get a prescription filled at her local Walgreens. The prescription was for misoprostol, a drug that is often used to induce a medical abortion. It was prescribed to Arteaga by her physician for the reason that, after nine weeks of pregnancy, the development of the fetus has ceased. Without intervention Arteaga would have had a miscarriage, and was advised that the best course of action in her circumstances was to terminate the pregnancy early. The pharmacist, however, refused to fill her prescription, on the basis of a moral objection. Arteaga expressed in tweets and interviews afterwards that although she clearly explained to the pharmacist at the time that her situation was urgent, and while the pharmacist recognized that she was in distress, he nevertheless refused to fill her prescription. Continue reading “Walgreens and the Conscience Clause”

Solving Antibiotic Resistance with the Power of Evolution

Photograph of several petrie dishes with growing cultures in them

The problem of antibiotic resistance is real and growing. It is estimated that 700,000 people die from antibiotic resistant infections each year [1]. Further, every year, new multidrug resistant organisms emerge. We might soon face the global crisis of an era in which there is massive spread of bacterial diseases that cannot be treated by any currently available drug. In order to solve this problem, we must recognize that it has both scientific and ethical components: each time a physician prescribes an antibiotic she or he is required to balance individual patient needs with societal risks and benefits [2]. Further, even in the absence of antibiotic use, resistance is, and always has been, an evolutionary problem – natural reservoirs of antibiotic resistance exist even in pristine environments [3]. Added to this is the fact that over the last thirty or so years there has been a decrease in the number of antibiotics that have been developed and approved [4]. These factors make the problem of antibiotic resistance multifaceted and complex, but recent advances in basic scientific research show a promising way forward, even though previously implemented strategies to mitigate the problem have been largely unsuccessful. Continue reading “Solving Antibiotic Resistance with the Power of Evolution”

“Minibrains” May Be the Future of Drug Testing. They Also Pose Difficult Ethical Questions.

Image of a scientist swabbing a petri dish.

Minibrains sound like science fiction, but they have already led to new discoveries in the medical sciences. NPR recently reported on the efforts of scientists who are growing small and “extremely rudimentary versions of an actual human brain” by transforming human skin cells into neural stem cells and letting them grow into structures like those found in the human brain. These tissues are called cerebral organoids but are more popularly known as “minibrains.”

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The Ethics of Short-Term Medical Missions

Photo of a doctor giving an eye exam to a child.

According to NPR, doctors and medical students in the United States are increasingly seeking out programs that enable them to spend a limited amount of time (from weeks to months) in developing countries providing free medical care. This sounds like an unmitigated good thing, given the amount of need for medical resources in many parts of the world and the opportunity to save and improve lives that this represents. However, as has been a common refrain in discussions concerning foreign aid generally, helping residents of poorer countries can have numerous unintended consequences, and short-term medical missions are not exempt from this insight. The NPR article provides several examples of these unintended negative consequences:

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Questions on the Ethics of Triage, Posed by a Sub-Saharan Ant

an image of an anthill

In a new study published in Proceedings of the Royal Society B, behavioral ecologist Erik Frank at the University of Lausanne in Switzerland and his colleagues discuss their findings that a species of sub-Saharan ants bring their wounded hive-mates back to the colony after a termite hunt. This practice of not leaving wounded ants behind is noteworthy on its own, but Frank and fellow behavioral ecologists note that the Matabele ants (Megaponera analis) engage in triage judgments to determine which injured ants are worth or possible to save–not all living wounded are brought back to the nest for treatment.

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For Humanitarian Organizations in War Zones, the Ethical Challenge of Neutrality

An image of a cemetery near Mosul, Iraq

When institutions fail to fulfill their long-established responsibilities, other groups must fill the void and meet the needs that are going unmet. When this happens, the new responsibilities assumed can conflict with these groups’ prior expectations and prior responsibilities. In states of war and civil unrest, such problems are compounded a thousand-fold.

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Do Terminally Ill Patients Have a “Right to Try” Experimental Drugs?

In his recent State of the Union speech, President Trump urged Congress to pass legislation to give Americans a “right to try” potentially life-saving experimental drugs. He said, “People who are terminally ill should not have to go from country to country to seek a cure — I want to give them a chance right here at home.  It is time for the Congress to give these wonderful Americans the ‘right to try.’” Though only a brief line in a long speech, the ethical implications of the push to expand access to experimental drugs are worth much more attention.

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Should Conscientious Objections Apply to Healthcare?

An image of a surgeon operating on a patient.

While executive orders and high-profile legislation garner the most media coverage, much of the change that comes with a new presidential administration happens in the individual departments staffed by new political appointees. The current administration has pushed far-reaching changes regarding the place of religious belief in the healthcare system through actions at the Health and Human Services Department. I’ve previously covered the administration’s decision in October 2017 to widen the scope of exemptions to the contraception mandate. More recently, NPR reported that the Department of Health and Human Services is opening a new Division of Conscience and Religious Freedom to defend health care workers who object to participating in medical care for patients because of their sincerely held religious beliefs. Notably, the establishment of the division also reverses an Obama-era rule barring “health care workers from refusing to treat transgender individuals or people who have had or are seeking abortions.”

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CRISPR, Moral Obligations and Editing the Human Genome

A close-up image of a scientist examining DNA test results

As our understanding of the human genome improves, pathways leading in the direction of new and powerful technologies are cleared.  In recent years, scientists have developed a new technique called CRISPR, which allows them to edit the genome—adding, subtracting, or deleting pieces of genetic code.  This process has the potential to bring about significant changes in human health.  CRISPR could prevent children from being born with a wide range of painful or life-threatening conditions.  So far, scientists have used this process in attempts to prevent blood disorders, allergies, heart disease, and to mutate the genome in such a way that the resulting person is less likely to get HIV.   Continue reading “CRISPR, Moral Obligations and Editing the Human Genome”

Rules Versus Results in Vaccine Research

A photo of a person withdrawing medicine from a vial with a syringe

A group called Rational Vaccines, which conducted a clinical trial of a herpes vaccine, has brought legal and ethical standards for medical research into the news recently. The trial, conducted from April to August of 2016, used human subjects and was conducted in the Caribbean in order to avoid being overseen by the FDA or cleared by the institutional review board, or IRB, which is required of trials in the US.

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Who Should Decide Charlie Gard’s Fate?

Charlie Gard is an 11-month-old boy suffering from an inherited and terminal mitochondrial disease. He cannot move his arms and legs or breathe unaided. At the time of writing, Charlie was still in intensive care at a UK hospital. Charlie’s parents decided that Charlie should be brought to the United States to receive an experimental treatment that may help alleviate his condition. However, the doctors at the UK hospital decided that the experimental treatment would not likely improve Charlie’s quality of life. Since the parents and the doctors disagreed on what would be in Charlie’s best interests, the courts got involved.  The UK legal system has so far ruled that receiving the experimental treatment would not be in Charlie’s best interest, and Charlie should be removed from life-sustaining treatment to receive palliative care; the legal process is still in process concerning Charlie’s ultimate fate.

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Ryke Geerd Hamer and the Dangers of Positive Thinking

Dr. Ryke Geerd Hamer died on July 2. It was hardly noticed in English language media. This is not surprising as, indeed, he was an obscure person. But, unfortunately, his legacy lives on, and the harm he has caused far outweighs the media attention that he has been given (Spanish and German newspapers have dedicated more attention to his death). Continue reading “Ryke Geerd Hamer and the Dangers of Positive Thinking”

Drug Addiction: Criminal Behavior or Public Health Crisis?

It is painfully obvious that the United States is in the midst of an epidemic of opioid abuse. According to the US Department of Health and Human Services (DHHS), more people died from drug overdoses in 2014 than any other recorded year, and the majority of those overdose deaths involved opioids. DHHS and the Centers for Disease Control (CDC) claim that an increase in the prescription of pain medication is a primary driver of the opioid epidemic. According to the CDC, the amount of prescription opioids sold in the US has nearly quadrupled since 1999. However, Americans do not report higher levels of pain than they did in 1999.

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Respecting the Dead: The Case of Charles Byrne, the Irish Giant

Charles Byrne died quite young, at the age of 22, and quite tall, at approximately seven feet, eight inches. This is still tall for today, but must have been more impressive during Mr. Byrne’s short life in the late 18th century. According to an Ohio State University researcher, the average height for men in Northern Europe in the 17th and 18th centuries was only about five feet, five inches. Today, the average height for men in Northern Ireland has been calculated to be about five feet, 10 inches.

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On Labeling Over-the-Counter Homeopathy

Homeopathy, the medical philosophy that “like cures like,” is big business. According to the latest estimates from the Centers for Disease Control, $2.9 billion were spent in out-of-pocket costs by adults in the United States for homeopathic medicine in 2007. The medical philosophy of homeopathy, developed in Germany over 200 years ago, posits that any substance that produces certain symptoms in a healthy person can also be used to cure those symptoms in a sick person. Homeopathic cures introduce one of these substances to cure a person of their symptoms.

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Life, Death, and Cryonics

Cryogenics, also known as cryonics, is a form of preservation involving the storing and preservation of a body at very low temperatures in hopes of one day reviving and repairing the body. Although to date no humans have been revived after freezing, some scientists think they are coming closer to making revivement though cryogenics a real possibility. Recent reports of a terminally ill British teen being frozen upon her death have brought cryogenics and the ethical debates surrounding the topic back into the news.

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Pricing the EpiPen

American drug prices have long been the object of controversy, from the price hiking on AIDS treatments conducted by the now-infamous Martin Shkreli or the $1,000 per pill Hepatitis C treatment that prompted Senate investigation. The average American spent $695 a year on drugs ten years ago, and now spends $935. Recently, the pharmaceutical Mylan received extensive backlash for the increase in the price of EpiPens, which are used in emergency situations to save someone from a life-threatening allergic reaction. EpiPens now cost $600, a 450% increase from their price in 2004. Analysts have determined that the cost of the drug within each Epipen is about one dollar.

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Consent to Dying: The Case of Julianne Snow

Recently, a 5-year-old child named Julianne Snow passed away from from a neurological disease known as Charcot-Marie-Tooth, causing nerves in the brain to degenerate and loss in the muscles related to chewing, swallowing, and eventually breathing. Although Charcot-Marie-Tooth disease is one of the world’s most commonly inherited neurological disorders, this story made national headlines due to Julianne’s independent decision to refuse treatment.

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Learning How to Die: Lessons from Oliver Sacks

During my first year at DePauw, I was assigned a reading from a book called A Man Who Mistook his Wife for a Hat. My interest was so piqued by the assigned snippet that I couldn’t help but read the entire book. I was captivated by the accessible and insightful way the author, Oliver Sacks, relayed unique patient case studies that he had encountered in his career as a neurologist. Sadly, Oliver Sacks, who touched many people through both his medical practice and his writing and who made many lasting impacts in his field, passed away last Sunday, August 30, of terminal liver cancer. Continue reading “Learning How to Die: Lessons from Oliver Sacks”