I finally sent in the first round of medical school applications yesterday, so I've started reading again. Right now I'm reading a little book called Medical Ethics - A very short introduction by Tony Hope. Euthanasia was the subject of the first chapter.

Euthanasia: X intentionally kills Y, or permits Y's death, for Y's benefit. (Medical Ethics and Law)

Is it wrong? What kind of euthanasia is wrong? For instance passive euthanasia, where the doctor allows the patient to die by witholding or withdrawing treatment, is widely accepted. Active euthanasia, where the doctor performs an action that results in the patient's death, is not widely accepted. Is voluntary euthanasia (patient competently requests death himself) wrong? What about non-voluntary euthanasia (where the patient isn't competent enough to express a preference, like a severely disabled newborn)?

The author rejects the view that voluntary active euthanasia is wrong. As an argument, he uses a few thought experiments, where hypothetical situations are formed in order to isolate the morally relevant features of more complex situations. In one case, person A breaks into a house and drowns person B while they are taking a bath, holding him under water. In another case, person A breaks into the house with the intention of drowning person B in the bathtub, but finds that person B has already slipped, hit his head, and is drowning in the bathtub. Person A could easily save person B, but stands around, ready to push his head back underwater should it rise. It never does, and person B dies. Is there a moral difference between person A's behavior in each situation? This pair of cases is used by Hope to support the view that there is no moral distinction between an act (killing) and an omission (failing to save) when the outcome and intention are the same. I would tend to agree that the act of withdrawing life support or withholding necessary medicine isn't any different than giving an overdose of morphine to kill the patient. Some might point out that the patient might live on their own after life support has been withdrawn, but if the doctor is intending for the patient to die, the outcome shouldn't affect the morality of the actual decision. In other words, if a man shoots another man, intending to kill him, his decision to shoot isn't less wrong if the other man survives.

Hope also examines what makes killing wrong. Many people don't agree with euthanasia on the grounds that killing is morally wrong. In the case of euthanasia, the wrong of killing is not even balanced by saving any other life. He says the reason killing is a great wrong is because dying is normally a great harm. Dying is normally a great harm because normally, people would much rather live. But if it is in the best interests and desire of the patient to die rather than continue to suffer, dying is no longer harmful. As a result, when death is a benefit, killing is no longer wrong.

Another thought experiment that looks at ethics more generally: A runaway train is travelling towards a fork in the rails. On one path, 5 people are tied down. On the other, one person is tied down. Unless you switch the fork, the train will continue towards the 5 people. Do you hit the switch, and sacrifice one person to save five (you can't stop the train or get the people off the tracks)? In another case, how about for organ donation? Should you kill one healthy person and use his organs is they can save the lives of 5 people? I think most people would switch the points on the train tracks, but not kill the healthy person to use his organs. These cases are used to show that even though the outcomes are the same, many times the actual act makes a moral difference. That's an example of why, Hope argues, we must not be too inflexible in applying our moral principles. Why is it necessary to adhere to strict moral principles in cases where people are being hurt because of them? One point on which I agree with the author is that flexibility is important. The world changes and we are presented with new situations everyday that could never have been foreseen. The decisions made in these situations can't always come from a an inflexible formula or ethic. Hope says "Consistency and moral enthusiasm can lead to bad acts and wrong decisions is pursued without the right sensitivities." More later.

I just saw this (quicktime) video about the September 11th attacks, and it raises some very interesting issues. One of the main questions is how at least 3 steel-constructed buildings (including the towers) collapsed, seeing as how no steel building has ever collapsed from fire. Jet fuel doesn't burn hot enough to melt steel. It goes through a lot of other claims about the alleged plane hitting the pentagon as well, and while I'm not suddenly convinced there's a huge conspiracy, the video has raised the eyebrows of everyone I know who has seen it. If the facts are right, there's definitely some suspicious goings on. Take a look, with a grain of salt.

Update: This Popular Mechanics site debunks a lot of the conspiracy myths surrounding 9/11. I can't remember the video well enough to say if it debunks all the info presented in the video, but it definitely addresses some of the claims. Thanks to Jeff Moher for bringing this site to my attention. And ruining all my fun.

While at jury duty yesterday, I finished Complications - A Surgeon's Notes on an Imperfect Science by Atul Gawande. It isn't a page-turner like First, Do No Harm was, or even House of God, but it is well written, easy to understand, and probably a good book for anyone to read, not just pre-meds. The book has many interesting passages about the uncertainties of medicine. One, about gastric-bypass surgery (where the stomach is stapled so it can only hold a small amount of food, and part of the small intestine is removed so less food is absorbed) for extremely obese people, also talks about diets. Surprisingly, almost all diets ultimately fail.

"A 1993 National Institutes of Health expert panel reviewed decades of diet studies and found that between 90 and 95 percent of people regained one-third to two-thirds of any weight lost within a year, and all of it within five years...One group of human beings that stands in exception to this doleful history of failure is, surprisingly, children...those [obese children] who received simple behavioral teaching (weekly lessons for eight to twelve weeks, followed by monthly meetings for up to a year) ended up markedly less overweight ten years later than those who didn't; 30 percent were no longer obese. Apparently, childen's appetites are malleable. Those of adults are not."

More related to the theme of an "imperfect science" is the passage about autopsies. Generally, they are used in hospitals to determine whether there was a mistake made in diagnosing the deceased patient. The number of autopsies has decreased recently, possibly because physicians are more confident in their diagnoses, especially with all the high-tech equipment used to help them. However, according to three studies done in 1998 and 1999, around 40 percent of autopsies reveal a misdiagnosis. On top of that, in about a third of the misdiagnoses, the patient would have been expected to live if the proper treatment had been administered. Surprisingly, the rate of misdiagnosis has not improved since at least 1938. These are incredible numbers. I doubt anyone would have guessed these kinds of figures without some research. Since these figures were so hard to believe (especially with our new high-tech tools like CT scanning, ultrasound, and nuclear scanning), doctors at Harvard looked at autopsies in 1960 and 1970, before these technologies, and then in 1980 after those technologies became widely used, to see if there were fewer misdiagnoses once new technology was used. No improvement. What does that mean? Is the new technology useless? Actually, Gawande says "In most cases, it wasn't technology that failed. Rather, the physicians did not consider the correct diagnosis in the first place. The perfect test or scan may have been available, but the physicians never ordered it." The more I learn, the more difficult being a good doctor sounds. Order all the tests for all possible diseases fitting the symptoms? Or go with the most likely disease, relieving the insurance/patient from paying in money, pain, or time, for useless tests? Somewhere in the middle? Where? And don't ever mess up. Ever. As Gawande says "No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it."

One last note for you all to keep in the back of your mind when facing serious medical problems. Regarding decision-making in medicine, Dartmouth physician Jack Wennberg's research has shown

"that the likelihood of a doctor sending you for a gallbladder-removal operation varies 270 percent depending on what city you live in; for hip replacement, 450 percent, for care in an intensive care unit during the last six months of your life, 880 percent. A patient in Santa Barbara, California, is five times more likely to be recommended back surgery for a back pain than one in Bronx, New York. This is, in the main, uncertainty at work, with the varying experience, habits, and intuitions of individual doctors leading to massively different care for people."

Complications shows how these differences can happen, and it's all explained so that the errors and uncertainty are understandable if not always forgiveable. Anyone itching to blame doctors for all medicine's problems or praise them for solving all medical problems should probably read this book.

New pics are up from Kuerner's Farm.

It's been a while since updating, mostly because my computer's been out of commission for a while. My monitor had been flickering for a long time, and it finally quit. Just when I needed to be working on these med-school applications. I decided to find a used monitor around Ann Arbor, so I brave the 90 degree heat in my car without air conditioning, drive to 2 stores, and finally buy a monitor at Computer Alley on Jackson Road. They're selling a used 17" monitor for $45, and though it's not plugged in, I assume they wouldn't have bought a used monitor that didn't work, so they wouldn't be trying to sell me one. Delighted by the deal, I load the 17" monitor into my car without air conditioning. It's about 110 degrees outside by now and I'm sweating so much it's getting hard to see. After lugging it all the way up the stairs in my house without air conditioning I plug it in, only to find out, surprise surprise, that it doesn't work. It's so faint that I have to make a tunnel with my hands like I was looking at something glow in the dark just to barely see what's on the monitor. I call up the store.

"You sold me a monitor, and I can barely see the screen. I checked the brightness options on the monitor"

"Oh, did you check the gamma settings inside the display menu after you click properties and advanced opt.....(blah blah blah I'm totally lost)...so you should probably try that."

"um..ok...let me see If I can find..."

"Ok bye."

Argh. So now I have to drive all the way back there and return this monitor. Oh well. I guess I should never assume used parts work. The day after I got the non-functional monitor, I went up to visit Eric in Grand Rapids for the weekend. Highlight of the weekend: A girl, on her way to her bachelorette party, somehow manages to swing her front tires into a ditch while backing out of a driveway. The front right wheel is covered in mud while the back left wheel is about a foot off the ground. Since there wasn't any damage and no one was hurt, everyone got a good laugh out of it. Not two minutes after her getting out of the car, it starts to pour on us. The seven of us guys at the barbeque decide to wait the rain out. Halfway through the flood, we realize the car is halfway in a ditch and go check on it, finding the water rising up to the engine compartment, so we decide brave the rain and push the car out. Everyone strips down to just shorts. It's still pouring. Walking to the car, it's freezing. I step into the ditch to look at the wheel, and I sink to my ankles in mud and who knows what else. It's disgusting, and the rushing rain water is almost up to my waist. After placing a few 2" by 8" boards under the tire, we heave and heave and finally, we're able to push the car out of the ditch. Miraculously, it starts. After a few congratulatory pats on the back, we triumphantly call the girl whose car we rescued (she is at her bachelorette party by now) and give her the great news. "Oh ok. Thanks." That's it. Oh well. Anyway, we then realize that we're already soaking wet, and in the middle of a flash flood with 2" by 8" wooden boards. Time for some street surfing. I'm not too good.

Sunday night, I drove home and went to PalaceVision to watch the Pistons get stomped by the Spurs. Embarrassing. Today, I finally brought a working monitor from Dearborn to Ann Arbor, so I thought I'd update. I think now I'll work on putting up those pictures from the weekend in Philadelphia. I know you're all salivating.

I had a nice weekend in the outskirts of Philadelphia. The highlight of the weekend was visiting relatives on a farm in Chadd's Ford. The farm has been in the family for a few generations and what makes it special is that Andrew Wyeth, a famous american painter, painted about half of his paintings there at Kuerner's farm. It has enough historical significance for the museum to give tours through their farmhouse. Being near the Brandywine battlefield, the farm has historical significance even beyond Andrew Wyeth. By some accounts, and judging from all the Revolutionary War era ammunition, a makeshift hospital during the Revolutionary War may have stood where the farm house stands today. Pictures coming soon.

On the trip, I finished up First, do No Harm. A very emotional book, it did more to illustrate the terrible dilemmas that hospitals face than give answers about the right way to handle them. The title is the basis of the main question of the book. It's an easy enough goal to do no harm, but what exactly is harm? Are you harming someone by repeatedly subjecting them to painful procedures with little chance of success that only prolong a painful life, or are you harming them by letting them die? Is a child harmed when their life is ended to avoid a low-quality life? How about an absolutely terrible-quality life, or something in between? Even though the book can be depressing, I would recommend it to anyone considering medical school. Speaking of depressing books, I also started reading House of God. It has been hard to put the book down, but it is terrifying. It's a novel about an intern in a hospital that, so far, has learned only that he doesn't do much but send patients elsewhere to other services in the hospital. Although it's a novel, it's written by a doctor currently teaching at Harvard Medical School and supposedly has a lot of truth in it. Unfortunately, I'm not sure about what's true and what isn't, because some of the scenarios are so different from what medicine seems to be. It echoes the subtle theme in my Medical Sociology class that modern medicine doesn't do all that much. It's scary because doing something meaningful and important with my life is a big part of why I want to go to medical school. I'm afraid to believe the novel. Luckily, even if the novel is true, it doesn't completely apply to me because, as of now, I'd like to do research in addition to seeing patients. Ideally, any emotional shortcomings of patient care will be balanced by the appeals of research and vice versa. Still, I hope the novel has an encouraging ending or I find out much of it is blown out of proportion. If it isn't, at least I will have a better idea of life ahead of me. It'll be good to face any fears I might have about my career path because if I can even begin to understand the worst aspects of being a doctor and continue aspiring to become one, that's a good sign. Hopefully.