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Cold and Calculating NICE

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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Slaves to consent?

Nature reports that in response to analysis done by bioethicist Robert Streiffer (and published in the Hastings Center Report), Stanford University may withdraw the use for research of several of its publicly funded stem cell lines because of concerns about consent. In 2001 President Bush decreed that only lines already in existence would be eligible for federal funding – 21 lines were subsequently approved by the NIH.

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Saving the planet by reducing birth rates

Climate change will impact the well-being of future
generations, directly by, for
example, increased intensity and frequency of extreme weather events such as
heavy storms. It will have also indirect
impacts on human heath – via cardiovascular diseases or by a rise in epidemics as emerging disease leave
the tropic and go North.

 
The beginning of this year, the British Medical Journal
declared that since climate change impacts public health, doctors have to deal
with it. And in tackling the problem, John Guillebaud, emeritus professor of
family planning and reproductive health at University College London , and GP
Pip Hayes from Exeter suggest that doctors should talk to their patients about
climate change and encourage them to think about the environmental impacts of
having a big family: see for example the Editorial
or an article
in the Daily Telegraph, or the Guardian.
After all, “each UK birth
will be responsible for 160 times more greenhouse ags emissions […] than a new
birth in Ethiopia.”

 
Fair enough, the world is
interconnected: environmental changes involve impacts on the population, and
changes in the population impact the environment. But is it sensible to treat
environmental problems not primarily as such, but making them problems of
family planning?

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How to Win the War on Drugs in Sport

Drug scandals again tarnish the Tour de France. Last week three riders, Spaniards Manuel Beltrain and Moises Duenas and Italian climber Riccardo Ricco, winner of two mountain stages, failed tests for the banned performance enhancer EPO. This year has seen fewer spectacular expulsions, but of course the game is not over.

Does this mean the drug testers are winning the war on drugs? It might. But it might also mean that cyclists and their doctors are getting better at evading testing. A recent BBC investigation supports the latter conclusion. WADA labs have been proven to fail to pick up positive results. There are 80 copy-cat drugs, produced in China, India and Cuba, which are difficult to detect. And labs apparently collude with doctors to “exchange knowledge” on testing procedures. Expert Professor Bengt Saltin, a leading anti-doping expert and a former winner of the IOC Olympic Prize, the highest honour in sports science, said

"I would think that most of the medal winners and many in the finals of endurance events – there is a big risk for them having used EPO."

So despite the numbers of athletes being prosecuted for EPO declining by two-thirds between 2003 and 2006, Professor Saltin concluded this was due to evasion, not a reduction in use.

"The reason that I am still a little bit upset with the whole situation is that I have seen too many suspicious samples that are clearly abnormal. Athletes are getting away with it. Look how many have been caught for EPO misuse recently."

The response is predictable: widen testing critieria. Experts have suggested that urine samples should be tested for any evidence of naturally produced EPO. If there is none, it should be classed as suspicious because the use of artificial EPO for doping causes the body’s own production to shut down. These experts also call for testing of blood profiles as well as the urine. An analysis of the number of young red blood cells can also indicate doping.

Is this a solution? No. It will simply escalate the war to the next level. History has proven the ability of athletes and their doctors to ingeniously evade detection. We will never win the war on doping.

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Should Karadzic be Punished?

Yesterday the world celebrated the arrest of Radovan Karadzic, the ex-Bosnian Serb leader who has twice been indicted by the UN War Crimes Tribunal in the Hague, and is charged with – among other atrocities — ordering his forces to kill at least 7,500 Muslim men and boys in Srebenica in July 1995 as part of a campaign to terrorize and demoralize the population.

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The world’s failure to fulfill its goals

The Guardian reports that the world is not on track for meeting the UN Millennium Development Goal to halt and reverse the increase in Malaria by 2015. While the funding for malaria prevention has increased up to $1 bn per annum, this is not enough to meet the declared goal. Indeed, while the figure sounds high, it is only $1 per person at risk or 0.002% of world GDP, which is not much for one of the UN’s major poverty reduction targets. Scientists at the Kenya Medical Research Institute estimate that 50% to 450% more funding is required to make the target. Sadly this situation with the malaria target is not unusual: the current estimates are that we will fail to meet every single one of the Millennium Development Goals (MDGs).

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Reproductive science: is there something we’re missing?

Thirty
years after the first test-tube baby, Nature
asks various experts for their views on what the next thirty years of
reproductive medicine will bring.
Some of the more startling predictions are:

  • No more infertility, with both children and 100-year-olds able to have children
  • Embryos created from stem cells, increasing the ease of embryo research and genetic engineering of children
  • … with the resulting greater availability of embryos making it easier to create cloned humans
  • Artificial wombs, enabling babies to develop outside the mother’s body
  • … which, some worry, could become compulsory as an alternative to abortion, or to avoid premature birth or fetal alcohol syndrome
  • ‘Genetic cassettes’ implanted in embryos to counteract the effects of inherited diseases
  • Increase in litigation following evidence that IVF babies may later suffer adverse effects from the environment in which they were grown as embryos

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