Terri Schiavo, once again.

Both Jake and Talcott have posted some interesting, and particularly reasonable stuff on the topic recently. In Jake’s case, he points out that the judges involved interpreted the law(s) correctly, and don’t deserve the utter and complete trashing that they’re getting in conservative circles. (I’ve been trying, very poorly to make that point for weeks now.) In my opinion, the big lesson from the whole mess is that, in the future, state legislators would do well to very, very carefully word such statutes.

Talcott raises a number of interesting items, and is definitely worth reading. I am a little disturbed that he said that I’m making strong arguments that Terri is PVS. I’m not a neurologist, and her medical records are quite rightfully sealed, so we *may* have one leaked scan film out a stack of hundreds. (It is worth remembering that most of the doctors commenting on the case haven't seen any medical records either, and there are patient confidentiality concerns that should restrain the ones that have from too much public comment. ) I’d like to think that instead, I’m making strong arguments that from what we do have available; we cannot assume that Greer, and especially the 2^nd Circuit Court of Appeals made an incorrect determination. The main reason that I’ve argued medical issues at all is because of the tapes, and in responses to issues others have brought up.

Short, and mostly tangential thoughts:

1. There is a split in the conservative blogosphere as to how to interpret the presidential approval rating drop. This is amusing to me, but I have no real opinion yet on the topic. Anyone care to speculate on how the drop relates to the distaste most americans have for the congressional intervention?

2. I’m tired of seeing Dr. William Hammesfahr on TV, and his words parroted without thought. (A good example is the eeg issue that I already brought up, if you can get useful information from an eeg of a patient during a seizure, his claim that Terri was too restless despite the fact that he wasn’t present requires some critical thought). Oh, and lets stop calling him a Nobel Nominee(I've been curious about that for weeks, and just this morning got around to firing up google on the topic.)

3. Why is it that people are so convinced that the courts have erred that they’re doing civil disobedience to bring Terri bread, and threatening to kill Greer, etc, while the other side is content to let Terri live if the courts rule that way? Six months ago, I don’t remember hearing about a bounty for euthanizing Terri, and noone has been arrested with a syringe of whatever sneaking into her room.

4. I think part of the answer to Talcott's concern about how to establish consciousness from a biological standpoint has to be based in eeg or similar measurements, not just in a percentage of brain area(s) left + clinical exam. Although I have the utmost respect of the privacy of medical records, and do not wish this case to become a precedent for trying end of life cases publicly in the press and polls, I wish I had more information on the eeg’s in this case.

5. Jeb Bush and others seem to think that part of the problem with this case is that the trials and appeals were always in front of judges, never a jury. I have reservations about mandating jury trials in this situation. In criminal cases, it is recognized that there are matters so emotional or technical that a defendant would prefer a bench trial. (Not to mention that given the current rules of evidence that some material is too emotional or prejudicial to go in front of a jury.) How the heck do we decide if the incapacitated person would want a jury or bench trial?

*Edited for blogger related spell check errors and to throw in a couple more links.

I know, I know, everyone is completely sick of it...But, here's a link to the what's purported to be THE CT scan over which so many comments have been shed in the HBC.

In related news, the Texas futility care law, signed by a certain former govenor in 1999, which allowed a hospital to remove support from a 6 month child last friday against the mother's wishes is a much bigger deal to me than terri shaiavo. Apparently there have been a couple of other kids too. Where is the outrage ? Other than in wildly liberal corners of the internet, and Texas local media it seems to be a complete non-issue. Is it because W. signed off on it, and it doesn't smell like judicial activism? Just to be ornery, what's to stop that from being a slippery slope precedent to requiring mother's to abort if serious birth defects are known? Texas is pretty high (~15th in the nation behind a suprising number of "red" states) on the abortions per capita CDC stats so the before birth, as opposed to waiting at least 10 days after, part shouldn't bother them too much. I would love to hear how this differs ethically from mandating certain abortions? Not to sound like a ranting liberal lunatic, but why the hell didn't "focus on the family", foxnews, World Net Daily, etc jump all over this story? To its credit, The Free Republic has covered it, but otherwise, the silence is deafening.

(Maybe I just live in a news-less hole here in law school and everyone has known about the Texas business for months? If so, my apologies for dragging up old news)

Quick thought about the school shooting tradgedy: the shooter wore stolen police body armor. So:

A. Regulating body armor is pretty pointless. So the police need to be able to shoot through it. This isn't a new problem at all, but it is defintely worthy of immediate attention.

B. If I were a police department armorer, I would be testing FN 5.7x28mm weapons, and possibly the new Russian 9x19mm PBP stuff too. Colt SCAMP anyone? Anyway, its high time to start arming police with armor piercing weapons. AP shotgun rounds would be a cheap start, but AP handguns would be best since it wouldn't get left in the car.

C. Maybe some of the 3/4 of a million M14 rifles that were crunched could have been passed out to police departments. Then again, its better for the economy for Springfield Armory to sell new ones, (slighly suspiciously without $270 foreign competition) for $1400 a pop.

You know, I usually make fun of the spray paint stenciling on this campus, including the ubiqous "Don't Rape" side walk items. I take at least some of that back:

I was walking out of "Sparty's" and over heard the following exchange:

Student "A": "Did you finally dump your creepy-ass boyfriend?
Student "B": "Yeah."
Student "A" Good, I hear he's a date rapist, that creepy...
Student "B" No, he just feed me drinks tell I passed out a couple of times, and sliped something it my drink once, or twice...
(At this point the conversation stopped because my head literally snapped around at that last comment, and they noticed)

That was, definitely a little wierd, espicially to over hear under-slept and insufficently caffinated on the way to class.

Schiavo

I've been putting this post off for weeks. Perhaps Talcott is correct and the silence has gotten deafening in the HBC on the topic. In any case, since I've already insinuated my position in Jake's comments, here goes:

I'm NOT campaigning to kill her, the whole mess is tragic, and I feel horrible for her family. I just think that she isn't a good candidate for martyrdom and extraordinary measures.

1. Legal Issues.

The evidentiary hearings seem remarkably through and extensive. This puts my mind almost completely at ease with regards to David's (an many others) concern that this will lead to a slippery slope of euthanizing the disabled. The precedent from this case is that a vast area of high quality brain scans, combined with a very solid majority of qualified neurologist testimony convinced a competent legal trier of fact. The hearing commentary and opinions seem brutally clear that if Terri had even a remote chance of recovery the outcome would be wildly different. Courts make life or death decisions all the time, and if one is comfortable with capital punishment, especially in states that historically screw it up, I don't see why one cannot trust this precedent.

2. Medical issues.

I REALLY hate the taped clips one sees on the news. I think they are wildly misleading, and cherry picked for emotional manipulation. As others have said, one has to either argue that the CAT scans are faulty, or that consciousness can occur without a cerebral cortex to make a argument for any actual thought or mental activity AT ALL. If a strong argument can be made for the first, I would be interested to hear it, and change my position on this topic entirely. If an argument can be made for the second, I would be dumbfounded.


Similarly, I dislike comparisons to cases where people miraculously awake from comas, "locked-in syndrome" and various neurological conditions. Those folks had a cerebral cortex of some sort. People seem to be using "miraculous" when they really mean "extremly unlikely but physically possible within the known laws of science".

3. Ethical Issues

Euthanasia.

I can respect, and find it logically coherent that some people believe in a sanctity of life approach that makes any attempt to remove life support, ever, unacceptable. (I do find some slight incoherence in objecting to the legal system making determinations in end of life issues while supporting capital punishment.) I don't happen to believe that myself, and to be brutally honest, I have several family members who have personally participated in what could be harshly called physician assisted suicide. I am NOT talking about Kevorkian like stuff, more the very, very rare prescribing of a on demand Demerol drip that crossed LD-50 but would still be inadequate to cover severe, terminal, cancer pain after discussing the issue with a conscious, and rational and coherent patient. I'm OK, if not comfortable with that, and very much OK with living will=removal of support situations.

Miracles.

There is no doubt that Terri’s family, and a great number of Americans are holding out for a miracle. God could make it happen. Her brain could regenerate overnight, and poof, she wakes up asking for a McGriddle. The same could be said for the cancer patient discussed above though or for anyone on life-support. I'm personally willing to let some chances for such miracles pass in the interests of preventing suffering. With all possible respect for people's opinions, I find it logically incoherent to believe that Terri should be kept alive at all costs hoping for a miracle if one doesn't do the same thing across the board with ALL end of life issues. From my perspective, if the CAT scans/interpretation is solid, a miraculous recovery is no more likely than it is that she'll live for 40 years without feeding.


4. Final Thought

I hate the whole business. I hate that millions of Americans have seen the tapes, and are emotionally pushed to positions they don't really want to hold. That's true on both sides, since a large number of us who make the no cerebral cortex=braindead connection are more or less forced to argue for killing her. I hate that I cavalierly discussed the odds of miracles above. I hate that by posting this, I will inevitably become classified as some sort of cold, utilitarian, progressive liberal. I hate the fact that Michael Schiavo may indeed be an evil asshole and completely made up everything about Terri's wishes. I hate the fact that her parents, IHMO, have been given a great deal of false hope. I hate that this seems to bring out everyone's irrational sides, mine included (yes, the tapes can make me emotionally react "oh crap, she's trapped in there"). I hate that some really, really bad law is likely to come out of this. I hate that a pretty decent sounding judge is being completely demonized. I am VERY willing to say that the world would be a better place if Michael Schiavo had been less stubborn or more greedy and simply took the cash and ran. Not because of ethical or medical reasons, merely so the whole damn mess would stop.

I've posted a lot of longish and serious stuff lately on herbal medicine. Since I don't want people to think I just sit around thinking profoundly all the time, I think some lighter material is in order:

The AK receiver project was successful, and one of the receivers has already seen about 200 rounds. I am curious about building some milled receivers now, or possibly some RPK stamped ones (I'd have to make a new die, or at least add some features to my current one to accommodate the RPK buldge trunnion.) Does anyone know where I can find a good milled AK blueprint? Or have one that I can measure for a couple hours?

While I was adjusting the rail positions on one receiver with my precision rail adjuster, my dad kept up a steady flow of derogatory commentary. Approximately 30 seconds later, he suffered a bizarre jam where his favorite M1 Garand's bolt rode over the top of a full clip (I have never seen or heard of this, much less on a good M1). After some minutes of trying to fix it, he finally had to admit defeat and borrow the rail adjuster and wood block to pound the op rod back. The irony was tasty, even if he tried to accuse my AK's of infecting his firearms with "communist problems".

To make up for his hurt pride, I did let him shoot an AK...and surreptiously took a picture :



(That should be a clickable thumbnail, so you can zoom in and see the nice, bone supported offhand postion! Even shooting an AK in the cold, wearing a redneck tuxedo instead of a shooting coat, his mind is elsewhere.)

Blogger is being...very annoying today. Expect a revised version of the alternative health issues post that Blogger just ate sometime this evening.

Anyway, for all of those who made snide IM comments about "making chips" last week, this is what I was talking about:

The Herbal Medicine debate continues.

Sarah Hemple has done a very nice job describing her personal medical experiences, which definitely helps give context to her other commentary. (It does make me wonder how much of her positive experiences with alternative therapy she attributes to placebo effect.) Since I am both lazy and less eloquent, I will provide a shorter version of my background:

Similar to Mr. Allen, I have seen stupid doctors, poor nurses, horrible insurance and HMO companies, and virtually every possible ethical and moral failing occur in the medical profession. My mother came very close to death in 1996 from a botched and unauthorized hysterectomy that caused ureic poisoning from a cut ureter. I’ve personally received some horrible medical treatment, namely in the form of inappropriate and potentially liver damaging prescriptions. I’ve also seen what Sarah would consider poor long term care strategies applied to my family members (Mother has M.S., paternal grandfather was paralyzed for 30 years following a car accident, etc). I do not have any illusions whatsoever about the medical community’s ability to screw up. (Not to mention two semesters of Torts, taught with an emphasis on medical malpractice law)

As a result, I most certainly do not recommend that anyone blindly trust medical advice, I’m skeptical about EVERYTHING, not just alternative medicine. In a perfect world, everyone would be able to maintain a long-term, preferably life long relationship with a trusted family practitioner, preferably a D.O. or at least an M.D. with a patient care focused education. Since that isn’t an option for most of us, whenever possible, I think in all non-urgent medical situations, one must educate themselves as much as possible, and do a great deal of risk balancing. This is where I find no substitute for double-blind, statistically valid studies. Also, as I tried to point out before, this is why I hate to generalize about ALL antibiotics, I want to look up the studies, probably on medline for a specific drug and weigh the risks.

Sarah apparently in non-emergency situations reaches first for alternative therapies, to quote “I think that lifestyle changes ought to be a first step, nutritional support through supplements, herbs and other alternative practices such as chiropractic, acupuncture, etc. only then should the patient turn to pharmaceuticals. I have no issue with being skeptical of pharmaceuticals, AS LONG AS ONE IS EQUALLY skeptical and demanding of the alternatives. Why should supplements, herbs, etc be given preference to pharmaceuticals? It certainly is not their amazing performance and lack of side effects. With the exception of a healthy diet, exercise, and limiting substance abuse, double-blind studies are not kind to non-pharmaceutical therapies. Steven Bratman has written a very nice and concise explanation of what I’m trying to say about double-blind studies, and I HIGHLY recommend that everyone read it. I am also very willing to argue or discuss his conclusions if anyone is interested.

As far as the placebo effect, I don’t have a problem with people knowingly finding a alternative therapy that they like for placebo reasons, as long as possible health risks are weighed. That is, there probably is a alternative therapy out there for everyone that has a beneficial placebo effect. Maybe going to a chiropractor and getting what amounts to a decent backrub, or getting poked with needles, or magnets, or whatever. As long as a person is doing it with their eyes wide open (i.e. avoids stroke risking abrupt c-spine manipulation, etc), I actually think it can be a good thing.

In the last paragraph, I alluded to a internal, psychological factor in the placebo effect. This is, I believe a very powerful and difficult to analyze factor, where a therapy that is functionally useless may create vastly improved sensations of well being because it happens to trigger or satisfy a certain psychological need. Maybe that need relates to tradition, or religion, or an experience growing up, or a desire to fit in, or whatever…the possibilities are endless. Perhaps the most interesting thing that I typically observe is a gender difference (Note, this IS NOT a personal attack on Sarah, and I nearly didn’t post it because I’m afraid it will appear so). I would say that many more women than men, at least in my social circles are interested in alternative therapies. Why? I don’t know, I’m working on that part. If I had to guess, I suspect that there is a psychologically strong appeal to…old traditions and pseudo-traditions of female wisdom, sort of like midwifery. I’m very interested in possible comments on the subject. And, of course if that came off as misogynistic let me know and I’ll try to rephrase it.

Finally, areas I can see the discussion going in:

1. I think Sarah hasn’t really responded to my criticisms of self-observation, and I’d love for her to discuss her views on the placebo effect.

2. Topics I can see the discussion expanding into: homeopathy, vaccinations, Faith-based healing/ “power of prayer”, Stem cells, etc. Since I’ve found the discussion interesting up to this point, I’m willing to pretty much go wherever people want with it.

There will be another round of the herbal medicine debate, just not tonight, I have way too much going on in the last couple hours of spring break, from hobbies to my personal life to write that post. Preview: I think Sarah is dodging my criticism of self-observation, and I think that she needs to do some serious work to argue agaist my demand for double blind studies. I also think that the placebo effect is gender dependant, stay tuned.

In other news...I want broken microwaves...at least 20 or so. Well cheap or broken arc welders might provide the correct parts too. Evil plan #496 is now under way.

Self-Observation; how I learned not to trust myself and you shouldn’t either.

This is in essence a very long response to Sarah Hemple’s comment on the Ockamist.

Holistic medicine

I completely agree that a balanced diet, exercise, etc all amount to a solid disease prevention strategy. However, I completely object to the characterization of western medicine as somehow inferior in holistic/wellness issues. Certainly my view is somewhat slanted because my family consists mostly of DO’s and biomedical engineers who tend to view treatment holistically, but I’ve never been to a physician that did NOT inquire about wellness concerns of balanced diet, exercise, and substance abuse. Western medicine is increasingly wellness oriented, if anything I would consider the restraining factor to be insurance companies not the medical professionals.

<>Self-Observation

I have no respect, other than as amusing reading, for non-double blind self-observation in medical treatment. I am completely convinced that completely rational individuals cannot observe their own medical reactions objectively. Even if the observation is of a laboratory experiment that has nothing to do with personal health, bias and emotion plays a powerful role…I’ve learned this the hard way a couple of times in physics and engineering, where despite my best efforts, I observed what I expected rather than what was actually there (notably, I once measured velocities for non-existent Milikan oil drops, probably picking dust particles in the microscope…and, surprise, surprise, I calculated a nearly correct value for the experiment.…).`

<>I firmly believe that there is a reverse placebo effect where completely rational and intelligent persons either suffer “medical student hypochondria”, or merely observe side effects suggested by reading the packaging inserts. If medical students, future doctors, with highly honed science backgrounds and powers of observations suffer objectivity problems and report symptoms of diseases they DO NOT have due to suggestion; the rest of us are certainly fallible as well. I have no respect, other than as amusing reading, for non-double blind self-observation in science. In my mind, an assumption of fallibility of an individual’s observations is the basis of all experimental design.

In other words, if one reads jitteriness on a prescribing insert for Allegra, or hears about it from friends or on the Internet, they have a wildly increased chance of noticing jitteriness. If, one read an equivalent side effect sheet on an herbal…since Sarah kindly brought up it up, why not St. John’s Wort, which has pretty stiff side effects, they might well experience those symptoms.

A question to those who would defend self-observation on holistic grounds…(i.e. what makes you feel good is good medicine), can you still object to patent medicines that depended entirely on placebo effect combined with low doses of mild intoxicants (alcohol, opium, hash oil, ether)?

Finally, I’m willing to argue all of Sarah Hemple’s generalizations about specific drugs; example: sure antibiotics can cause yeast infections, but how often, how severe, and whether that’s preferable to the original condition is debatable. I’m not going to write a 7,000 word detailed paper on the different types of antibiotics, etc, but if anyone wants to argue with specifics and cites, I’m ready. Want to argue effectiveness, in double blind testing, of herbal “x” v. pham. Drug “y”, and compare side effects, I’m willing to discuss it. What I don’t want to do is argue against unsupported on non-specific generalizations, i.e. “Anti-depressants cause anti-personality, St. John's wort actually works and so does exercise.” Along the same lines, I coiuld say, St. John's Wort causes high blood pressure, nausea, and completel dementia if you take imodium or pepto-bismal while on it...but I do not want to generalize a rare side effect into "causes".

Pet Peeve #2: A lower burden of proof for Herbal or Natural products compared to pharmaceutical products.

A. I have nothing specifically against herbal stuff in and of itself, it is merely another way to get chemicals into the body. It also is another way to induce a beneficial placebo effect. Somewhat unfortunately, the actually therapeutic chemical(s) in herbal products are often part of a chemical sea of other agents. This is not in and of itself always good or bad, I'm comfortable taking the risk of eating all sorts of food items that contain dangerous chemicals.

B. The problem, which unfortunately is intertwined with placebo effect, is the blind and irrational faith that many otherwise bright people put in herbal/natural/organic/whatever products. Setting the bar lower for herbals makes the placebo effect work better, I suspect.

100. Practical example: if a friend had hay fever...and I offered them the same random appearing pill as:

101. 1. Oh, its an experimental allergy drug “X-679” from britsol-myers-squibb, it's been doing great for people, there are all sorts of good reports about it on the internet! They really have out best interest in mind even though they don't have any double-blind tests done yet, or a well researched side effect list! Better living through chemistry! I've been taking it for months and it makes me feel great! So has my family!
     

2. This is the Pos weed caplets I was telling you about! Just look on the internet! The Native-Americans and pioneers used Pos weed for generations to treat this problem! It is completely natural, had nothing whatsoever artificial in it, no dies, etc, etc. Of course it doesn't have side effects, ITS NATURAL! Double blind testing is just a way for pharmaceutical companies to keep cheap and effect natural ethanobotanicals from competing in the marketplace, and the FDA is of the devil for putting a cautionary label on Pos weed!

I'd lay pretty heavy odds on more people taking the pill with scenario #2, than #1. I could have fleshed out that hypothetical with making the active ingredient the same, or that the random other alkaloids in Pos Weed are many, many times more likely to be dangerous than the binders and dyes in 679, etc, etc. If I had to pick a real world equivalent off the top of my head I'd use Khat v. Pseudoephdrine. Anyway, I can always do that in the comments if anyone cares.

E. The sociological issues here are fascinating: typically if I comment to friend that an antibiotic they're taking won't help their viral infection or similar, they are much more receptive than, oh, if I were questioing the effectiveness of Echinacea taken as an general immune system booster.

Often when talking about this issue, I use the “better living through chemistry” phrase, which I should change to “better living through balancing risks with hard data”. Personally, it never fails to amuse me the social and psychological stuff that's tied to herbals, so I should quit whining and just watch in bemusement.

Random factiods

A. I went with cingular, since that makes about 75% of my calling mobile to mobile. I apparently have, however, no friends as I've only received ONE call since getting it two days ago. Not that I'm complaining, it is nice to ease slowly back into an electronic leash. And if anyone cares: (517) 775 9815.

B. Due to my OH drivers license, the large quantity, and the OSU/MSU basketball rivalry, I was accused of plotting a mass murder yesterday while buying ammunition. Why was I buying lots of 7.62x39mm ammunition? Because: it was on sale, and I have to test all of the AK's I'm building this week. Why build AK's? Because I've never done it before and it IS legal and safe, I'll follow the silly 922 and NFA stuff. (insert evil laughter if the AWB comes back, and I have a lifetime supply of "pre-ban" experimenting fodder) Sigh, I really should be building .50 BMG rifles or some more really big lasers because that seems more easily linked to terrorism and banable. (And yes, I expect mr. frank to make a comment about the first line of paragraph 4 of the brady link.)


C. I had an utterly hillarious conversation with my dad yesterday where he discussed how much fun it was to get a complete blood workup by comparing it to doing spectro analysis on lubricating oil. That is...really twisted, though I should be simply happy that his numbers accross the board were very good, and I don't have to worry about a genetic predisposition to cholesterol issues or similar.

Cingular with a Motorola V220? Or, one of their other phones? Since at least some of the phone options are currently free ot cheap until Thursday...time is of the essence.

Or if you really hate cingular...vote for Sprint, though I *think* that most of my calling would be mobile to mobile on cingular.

I hate wierd ringtones, speakerphone features, and random breakable crap on phones, though I might get some use out of a camera phone for preventing "oh crap, how does this go back together" moments. I universally carry phones in my pocket, typically naked, but I suppose a "skin" case wouldn't kill me.