US servicemembers pictured from behind, saluting

“Homecoming” to a History of Servicemember Experimentation

Much ado has been made about Amazon’s new hit, “Homecoming,” which recently received three Golden Globe nominations, including one for best drama series. The psychological thriller, directed by “Mr. Robot” creator Sam Esmail and starring Julia Roberts, has been characterized as “an irresistible mystery-box drama” and “the good kind of ‘what the hell is going on here?’ TV.” Tim Goodman described the show, which was adopted from Eli Horowitz and Micah Bloomberg’s Gimlet Mediacult hit” podcast of the same moniker, as a “dazzling” play “on memory, the military industrial complex, conspiracy and unchecked government privilege.”

The series revolves around novice caseworker Heidi Bergman’s (Roberts) experiences administering the Tampa, Florida-based Homecoming Transitional Support Center (HTSC). HTSC is a privately-run, Department of Defense (DoD) contract facility, which purports to assist combat-traumatized servicemembers readjust from the battlefield and reintegrate to civilian life. Indeed, Bergman opens the drama’s aptly-titled pilot, “Mandatory,” by explaining to her “client,” three-tour-combat-veteran Walter Cruz (Stephan James), that the treatment facility is “a safe space for you to process your military experience and re-familiarize yourself with civilian life in a monitored environment, which, just means getting you situated now that you’re back home, rear-wise, health-wise, basically, I just work for you.” Read More

Close up on a pile of yellow pain pills

Addressing the Opioid Epidemic Starts with How We Treat Pain

As a nurse practitioner in a busy suburban emergency department, pain is my job. Pain is one of the most common reasons people come to an emergency department (ED). It could be abdominal pain, chest pain, back pain or even emotional pain, including depression or suicidal ideations. Pain is a driver for people seeking medical care. We have made pain into a vital sign, and we ask, “How would you rate your pain on a scale of 1 to 10?” a mandatory question for any patient who steps through our door.

This whole concept evolved circa 1987 when the Institute of Medicine urged healthcare providers to use a quantified measure for pain. It gained even more traction in 1990 when then president of the American Pain Society, Dr. Mitchell Max, called for improved means to assess and treat pain. The term “oligoanalgesia” gained popularity in the published literature, meaning that we weren’t giving enough pain medication to patients in the ED, in clinics or in any other healthcare setting. Healthcare providers responded. We asked about and we thought, more effectively treated pain to address this issue.

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The Emergency Department is The “New” Frontier of Public Health

I had always considered my field of expertise to be emergency medicine. I worked through the ranks as an emergency medical technician, then onward as a paramedic, which included a nine-year stint on a busy medical helicopter. I worked in disaster medicine, and was the associate director of a Harvard-affiliated disaster medicine fellowship in Boston. My current practice is as a nurse practitioner in a busy suburban emergency department (ED) and I am still active in emergency medical services as a SWAT medic and as an educator.

The emergency part of what I do is the exciting part —the part that stimulates the excitatory neurotransmitters that flood the brain, preparing it to act quickly and concisely.

We are selling ourselves short, however, when we label this role as “emergency” providers. Instead, “public health provider” is a much more appropriate term to use, because emergency departments and those who provide care there are really public health workers.

All of us who practice in emergency medicine know that real emergencies are few and far between. Our day-to-day is much more mundane. We deal with many urgent issues as well as some less urgent, primary care problems. We may even spend time filling printer paper or bringing a patient their lunch. We may help to find someone a homeless shelter, send a family home with warm coats for the kids, or pack up a bag with food and toiletries for a young girl we feel is being trafficked.

In light of all this, the purpose and the policies of the emergency department need to be redefined. Read More

image of hands texting on a smart phone

Artificial Intelligence for Suicide Prediction

Suicide is a global problem that causes 800,000 deaths per year worldwide. In the United States, suicide rates rose by 25 percent in the past two decades, and suicide now kills 45,000 Americans each year, which is more than auto accidents or homicides.

Traditional methods of predicting suicide, such as questionnaires administered by doctors, are notoriously inaccurate. Hoping to save lives by predicting suicide more accurately, hospitals, governments, and internet companies are developing artificial intelligence (AI) based prediction tools. This essay analyzes the risks these systems pose to safety, privacy, and autonomy, which have been under-explored.

Two parallel tracks of AI-based suicide prediction have emerged.

The first, which I call “medical suicide prediction,” uses AI to analyze patient records. Medical suicide prediction is not yet widely used, aside from one program at the Department of Veterans Affairs (VA). Because medical suicide prediction occurs within the healthcare context, it is subject to federal laws, such as HIPAA, which protects the privacy and security of patient information, and the Federal Common Rule, which protects human research subjects.

My focus here is on the second track of AI-based suicide prediction, which I call “social suicide prediction.” Though essentially unregulated, social suicide prediction uses behavioral data mined from consumers’ digital interactions. The companies involved, which include large internet platforms such as Facebook and Twitter, are not generally subject to HIPAA’s privacy regulations, principles of medical ethics, or rules governing research on human subjects.

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elderly person's hand clasped in young person's hands

How Would You Like to be Treated if You Had Dementia?

The New Yorker just published an article full of ethical questions about the best health care treatment for dementia patients. It should make you think about which life you would choose. Larissa MacFarquhar’s piece is titled “The Comforting Fictions of Dementia Care.” Its subtitle suggests a sad story, noting “Many facilities are using nostalgic environments as a means of soothing the misery, panic, and rage their residents experience.” The article tells numerous powerful stories of dementia patients’ good and bad experiences.

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Dementia, Disability, and Advance Medical Directives

By Rebecca Dresser

pencil drawing of a brain Anyone fortunate enough to live beyond middle age faces a risk of developing dementia. Dementia is a widely feared disability. People often say they wouldn’t want to live if they developed the condition.  

Experts in law and ethics praise advance directives, or instructions to follow on behalf of patients, as a tool giving people control over the life-sustaining medical care they later receive as mentally impaired dementia patients. Some advance directive supporters also want the law to recognize advance requests to withhold ordinary food and water in the late stages of dementia. And some argue that the U.S. should follow the Netherlands in allowing doctors to give lethal drugs to people who made advance directives asking for assisted death if dementia makes them unable to live at home or to recognize their loved ones.  

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From bioethics to medical anthropology to humanities and back: A year in review

I thought I would take this opportunity to reflect on the past year, where I will be in the future, and how the student fellowship has impacted me. I still hope to contribute to the Bill of Health blog going forward, but as my last official post as a Petrie-Flom Student Fellow, I would be remiss if I did not express my sincere gratitude to everyone at the Petrie-Flom Center, the faculty and staff, the other student fellows, and especially my mentors: Professors I. Glenn Cohen, Carmel Shachar, and Intisar A. Rabb.

My own project took a few different turns this year. My original proposal was to explore the ways in which bioethics and biomedical issues will play a significant role in reviving the dialectic between secular scholars and religious authority. Ayman Shabana rightly argues that respect for Islamic religious norms is essential for the legitimacy of bioethical standards in the Muslim context, wherein he attributes the legitimating power of these norms—as well as their religious and spiritual underpinnings—to their moral, legal, and communal dimensions. Building off of Shabana’s work, my initial argument held that the relationship between the secular and religious worlds is important because the discourse between the two, although often presumed to be dichotomous, is not necessarily antithetical nor is it impassable. This led me back to the arguments of the venerable philosophers Alasdair MacIntyre and Charles Taylor whereby, in critiquing the concept of secularism itself along with its historical contexts, furthered my argument and helped me to clarify the significant role that religion plays vis-à-vis categorical issues such as fundamental beliefs and metaphysics. I still maintain this, and it is something I continue to work on, although I decided to take my project in another direction.

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Culture, Medicine, and Psychiatry

By Yusuf Lenfest

Professor Robert Sapolsky, a professor of biology and neurology at Stanford University, rightly identifies depression as a particularly crippling disease insofar as it affects one’s very response mechanisms and modes of coping, namely, experiences of gratitude, joy, pleasure—at bottom, some of the key emotions of resistance and healing. In discussing depression, he provides an overview of the biological and chemical elements, touching on the role of neurotransmitters (epinephrine, dopamine, serotonin) in depression, and a summary of the psychological elements (and their relation to the biological); as such, his description focuses primarily on physical and biological explanations. However, to examine depression or any psychological illness in purely physical and biological terms misses a crucial element, namely: human culture, lived experience, and the different modes or methods of social thought. Culture plays a primary role in defining many mental disorders such as schizophrenia and psychosis, and even the symptoms, intensities, or typologies of depression, according to Arthur Kleinman in his seminal Writing at the Margin: Discourse Between Anthropology and Medicine.

Despite these findings, Western biomedicine by and large continues to analyze mental health in clinical and biological terms. This is not insignificant given the statistics:

  • Approximately 1 in 5 adults in the U.S.- 43.8 million or 18.5% – experiences mental illness in a given year.
  •  Approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder at some point during their life. For children aged 8–15, the estimate is 13%.
  • Only 41% of adults in the U.S. with a mental health condition received mental health services in the past year. Among adults with a serious mental illness, 62.9% received mental health services in the past year.
  • Just over half (50.6%) of children aged 8-15 received mental health services in the previous year. (National Alliance on Mental Health)

Current trends in medicine suggest that the medical community broadly speaking is ill-equipped to adequately tackle this rising trend, especially with regard to the treatment of diverse patients from various cultures, religions, and social circumstances. To best address the problem, the medical community – both on the level of policy and practice -ought to take steps to understand and treat mental illness more holistically.

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Simulated Side Effects: FDA Uses Novel Computer Model to Guide Kratom Policy

By Mason Marks

FDA Commissioner Scott Gottlieb issued a statement on Tuesday about the controversial plant Mitragyna speciosa, which is also known as kratom. According to Gottlieb, kratom poses deadly health risks. His conclusion is partly based on a computer model that was announced in his recent statement. The use of simulations to inform drug policy is a new development with implications that extend beyond the regulation of kratom. We currently live in the Digital Age, a period in which most information is in digital form. However, the Digital Age is rapidly evolving into an Age of Algorithms in which computer software increasingly assumes the roles of human decision makers. The FDA’s use of computer simulations to evaluate drugs is a bold first step into this new era. This essay discusses the potential risks of basing federal drug policies on computer models that have not been thoroughly explained or validated (using the kratom debate as a case study).

Kratom grows naturally in Southeast Asian countries such as Thailand and Malaysia where it has been used for centuries as a stimulant and pain reliever. In recent years, the plant has gained popularity in the United States as an alternative to illicit and prescription narcotics. Kratom advocates claim it is harmless and useful for treating pain and easing symptoms of opioid withdrawal. However, the FDA contends it has no medical use and causes serious or fatal complications. As a result, the US Drug Enforcement Agency (DEA) may categorize kratom in Schedule I, its most heavily restricted category.

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Dementia And The Law: P/Review 2017–18

This new post by Francis X. Shen appears on the Health Affairs Blog as part of a series stemming from the Sixth Annual Health Law Year in P/Review event held at Harvard Law School on Tuesday, December 12, 2017.

Another year, another failed Alzheimer’s drug trial. In what is becoming routine news, in 2017, another Alzheimer’s drug failed in clinical trial, leading to the apt headline: “The List of Failed Alzheimer’s Drug Treatments Keeps Growing.” Moreover, there seem to be few evidence-based options even to limit cognitive decline. Research continues of course, and there remain multiple—and potentially promising—pharmacological interventions in the Food and Drug Administration (FDA) pipeline.

One of the reasons that successful drugs have been elusive is scientists are still trying to figure out the exact underlying neurobiology of Alzheimer’s. The past year saw the publication of a major scientific study showing that in mice, the gene variant ApoE4 (which is linked to a much higher risk for Alzheimer’s) affects both β-amyloid and tau buildup in the brain. The study’s implication of tau was important because the scientific community has been debating the “amyloid hypothesis,” whether the field’s sometimes singular focus on β-amyloid buildup was misguided. This debate is so intense that in 2017 it even made its way to the pages of The Atlantic. […]

Read the full post here!