End-of-Life Care in NYC: Two Different Models

By Randy Hendrickson

The New York Times (May 30, 2008 http://www.nytimes.com/2008/05/30/nyregion/30hospitals.html?_r=1&ref=health&oref=slogin) reported that data from a 15-year research project (The Hospital Care Intensity Report) conducted by Dartmouth College show that there is a drastic difference in end-of-life care that is offered by private hospitals compared to public hospitals in New York City. In terms of aggressiveness of care, NYC’s private hospitals ranked in the 94th percentile, whereas the city’s public hospitals ranked in the 69th percentile. As would be expected, there was also a concomitant increase in the out-of-pocket expenses for private hospital patients versus city-run hospital patients ($4,000 vs. $2,200 in two years).

The study shows that the last two years of a person’s life (especially those who suffer from chronic illnesses) are often the time when the most intensive medical treatment is needed; however, more is not always better. Dr. David Goodman, one of the co-authors of the Dartmouth Atlas of Healthcare, the site where this report is published, claims that “the general principle is that greater intensity of care is not better, and at the high end can actually be harmful. New York’s healthcare system is full of ironies… and the dichotomy of treatment might illustrate how a city with an abundance of sophisticated doctors and wide disparities in patients’ income and education could result in unfair distribution of resources.”

Why is there such a dichotomy in treatment models? There are several possible explanations. Kenneth Rask, president of Greater New York Hospital Association explains that “the aggressiveness of private hospitals is attributed to both the sophistication of the patients and the intention of the physicians to give them the best possible care.”

Another less principled but probably more realistic view is that the physicians in public hospitals have no real financial incentives to order more tests or do more procedures. In addition, according to Dr. Eric Manheimer, medical director at Bellevue Hospital and clinical professor at NYU School of Medicine, private hospitals are often more disorganized with “specialists referring to other specialists, with nobody coordinating, which results in confused messages, more referrals, more hospitalizations, deterioration in health care, and a more anxious patient.”

New York state treats end-of life patient more aggressively than any other state, except New Jersey. In looking at the report, it is evident that the dichotomy of care is even more pronounced when compared with other states, especially western states such as Utah, Oregon, Idaho, Washington, and Montana.

Mothers' Little Helpers?

By Randy Hendrickson

A New York Times article ( “Experts Question Placebo Pill for Children” --May 27, 2008) raises the question of whether giving children placebo pills for minor childhood illnesses is an ethical practice. Based on the premise that pharmacologically inert compounds can actually produce improvements in some medical conditions, Jennifer Buettner, a mother of three small children, developed a cherry-flavored chewable dextrose tablet, the first branded, pharmaceutical grade placebo. The therapeutic effect is based on the power of suggestion. Parents use the placebo to “trick” their children into thinking that they are taking real medicine, and the children will consequently feel better. The placebo, called Obecalp™ (placebo spelled backwards), goes on the market on June 1 and will be available in retail stores and on the Efficacy Brands website.

Several bioethicists speak out about the use of placebos in children:

Howard Brody, MD, PhD, a medical ethicist at the University of Texas Medical Branch at Galveston, claims that there is no way to predict the response of placebos, especially in children. There may be a dramatic response in some children, whereas others may have no response at all. “The idea that we can use a placebo as a general treatment method strikes me as inappropriate.”

Franklin G. Miller, PhD, a bioethicist for the National Institutes of Health, agrees. “As a parent of three now grown children, I can’t think of a single instance where I’d want to give a placebo.”

There is also the question of deception:

Steven Joffe, MD, MPH, a pediatrician and bioethicist at Dana-Farber Cancer Institute, does not condone parents purposefully lying to their children. “It makes me squeamish."

In addition, other physicians have expressed concern that giving children a pill for every minor ache or pain will lead children to believe that you can only get better by taking pills or medicine. They will not come to realize that most ailments will eventually resolve on their own. This pill-taking behavior can carry over into adulthood. In most cases, what children really need is a little comforting, nurturing, and attention, rather than fake pills.

Jon & Kate + 9?

Jon & Kate + Ethics

By Michael Leshinski

You might be familiar with the popular reality series called Jon & Kate Plus 8 that airs frequently on The Learning Channel (TLC). As an avid TV watcher, I frequently have to share the remote with my female counterpart as she likes to watch the show. But I must admit, the kids are adorable and it can be entertaining at times. If you are unfamiliar with the program, it centers on a family of ten, including the mother, father, and their eight children. Kate, the mother, was originally unable to get pregnant due to Polycystic Ovarian Syndrome, a disease which affects the ovulation cycle of about 5-10% of American women.[1] In order to get pregnant, Kate underwent fertility treatments. In her first pregnancy, the treatment was successful and she eventually gave birth to twins. A few years later she decided to have more children and once again underwent fertility treatments. The second time around was also successful, but this time she gave birth to sextuplets.

What many people do not know is that a reduction was performed during Kate’s second pregnancy. This means that there were actually seven embryos, but she only gave birth to six. This is where the topic starts to heat up. Embryo reduction, also known as selective reduction or feticide, is often performed during fertility treatments especially when there is a birth defect or possible complication to the pregnancy. But what if no complications exist? What if the pregnancy is going smoothly, but the parents just want a certain number of children? Is it ethical to discard the third fetus, if you can only handle two? In this case, some could liken this to the abortion issue and the right for women to choose. In Kate’s case, I believe that she chose to do the reduction for the health of her and the other babies. You may still disagree with her decision.

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[1] http://www.nih.gov/news/pr/oct97/nichd-15.htm

The New Trend in Childbirth: Elective Cesarean Section

By: Jenny Walters

21 months ago I gave birth to my beautiful daughter through natural childbirth. During my pregnancy, I never once thought of undergoing a cesarean section (c-section). The only reason I felt a c-section would be warranted was in an emergency situation. However, following the birth of my daughter, I began to hear from more and more women who were scheduling elective c-sections.

A recent article in Time magazine written by Alice Park and entitled Choosy Mothers Choose Caesareans discussed the rising trend of elective c-sections. According to Park, c-sections accounted for 31% of all live births in 2006; a 50% increase from 1996.1 In places such as Brazil, c-sections account for 80% of all live births.1

The article focused on one mother who knew before she was married she would undergo a c-section. However, this mother did not base her decision to undergo a c-section on health related issues; instead she based her decision on the “combination of having watched traumatic vaginal deliveries in medical school and hearing about her mother’s difficult emergency c-section after trying to deliver vaginally.”[1]

Why are more women choosing elective c-sections?

Eugene Declereq, a professor of maternal and child health at Boston University School of Public Health, stated: “the biggest change may simply be the way we think about labor and delivery. In an increasingly technological and medicalized society, maybe even childbirth is losing some of its magic and becoming less about the miracle of life and more about simply getting a baby out safely and without incidence.”1

Cesarean Section Facts:

There are numerous reasons c-sections take place: [2]
· Placenta previa: Placental lies low in the uterus and partially or completely covers the cervix. Incidence: 1 in 200 women
· Uterine rupture: Uterus tears during pregnancy. Incidence: 1 in 1,500 births.
· Placental abruption: Separation of the placenta from the uterine lining that usually occurs in the third trimester. Incidence: 1% of all pregnant women.
· Breech position: Cesarean is usually only option with breech babies.
· Cord prolapse: Umbilical cord slips through the cervix and protrudes from the vagina before the baby is born. If this occurs, an emergency c-section is required. Incidence: very low.
· Fetal distress: Most common cause for c-section is lack of oxygen to the baby. An emergency c-section is required in this situation.
· Failure to progress: Occurs when the cervix has not dilated completely, labor has slowed or stopped, or the baby is not in an optimal delivery position.
· Diabetes: Gestational diabetes can lead to a very large baby, increasing the need for a c-section.
· Repeat c-section: A common misconception is, once you undergo a c-section, you must undergo another one for each subsequent birth. However, according to the American Pregnancy Association, 90% of women who underwent a c-section are candidates for a vaginal birth.

The risks involved in a c-section:[3]
· Infection: Incision site, uterus, or pelvic organs
· Hemorrhage or increased blood loss: 1 to 6 women per 100 c-sections require blood transfusions.
· Injury to organs: Bowel and bladder risk (2 per 1002)
· Adhesions: Scar tissue can form inside the pelvic area, causing blockage and pain.
· Extended hospital stay: 3-5 days
· Extended recovery time: Can be extended from weeks to months.
· Reactions to medications: Reaction to the anesthesia.
· Risk of additional surgeries: Example: Hysterectomy or bladder repair.
· Maternal mortality: The maternal mortality rate for c-section is greater than vaginal birth.
· Emotional reactions: Some women have negative feelings towards their birth experience.
· Breathing problems for the baby: When delivered via c-section, a baby is more likely to have breathing and respiratory difficulties.
· Low APGAR scores: Can be a result of the anesthesia, fetal distress before delivery or lack of stimulation during delivery. Babies born via c-section are 50% more likely to have lower APGAR scored than babies born vaginally.

What does this all mean?

As the article in Time came to a close, the author remarked on the soaring malpractice rates for obstetricians, and remarked: “doctors are sued more frequently after vaginal births than cesarean; surgery is often the prudent choice when there is even the slightest indication of a difficult vaginal birth.”

The soaring malpractice rates in combination with an increasing number of women choosing elective c-sections, forces one to ask: In the future will c-sections become more prevalent than vaginal births? Dr. William Callaghan, an obstetrician at the Center for Disease Control and Prevention stated: “We put a lot of emotional, psychological, and spiritual value around birthing. But perhaps we are coming up with different cultural norms.”1

For me, natural childbirth was a moving, humbling, and glorious experience. Although it involved a great deal of pain, it is an experience I would never take back.


[1] Park A. Choosy mothers choose caesareans. Time. April 2008. Available at: http://www.time.com/time/magazine/article/0,9171,1731904,00.html. Accessed on May 25, 2008.
[2] American Pregnancy Association. Reasons for a cesarean birth. Available at: http://americanpregnancy.org/labornbirth/reasonsforacesarean.html. Accessed on May 25, 2008.
[3] American Pregnancy Association. Risks of a cesarean procedure. Available at: http://americanpregnancy.org/labornbirth/cesareanrisks.html. Accessed on May 25, 2008.

Got $100k? Enter to Win a Canine Clone

By Chris Karlesky


Do I hear $100,000?

$150,000?

$200,000?

For the right price, a California biotech startup will clone dogs for five lucky bidders in the world’s first commercial dog cloning program. BioArts International opens a series of online auctions June 18, when people around the world can bid to have their four-legged friends “duplicated.” Bidding starts at $100,000.

BioArts chief executive Lou Hawthorne, who recently succeeded in a decade-long quest to clone his family dog, spearheads the program. Hawthorne (pictured with his cloned dogs) partners with Hwang Woo-suk, a South Korean scientist who led the effort to produce the world’s first canine clone in 2005. Hwang is also known for a series of embezzlement and bioethics law violations linked to fake stem cell research.

News of the BioArts auction is sure to spark debate among dog owners for both its controversy and opportunity. One one hand, the Humane Society argues that commercial pet cloning has no social value and may lead to increased animal suffering. On the other, Hawthorne views biotechnology as path to happiness for pet owners.

But can the scientists at BioArts duplicate an animal’s personality? When I was young, my family’s dog passed away after a long battle with cancer. I was devastated; I had grown up with Sam around, and his unique personality was a big part of our family. Even if cloning were possible at the time, I doubt the process could have replicated Sam the way we knew him.

The debate over pet cloning also raises the issue of homeless animals. The Humane Society makes a strong case for animal adoption over animal replication. Wouldn’t pet owners be doing society (and the animals involved) a favor to adopt animals from shelters rather than pour hundreds of thousands of dollars into an attempt at producing a genetic duplicate?

Will Hawthorne and his team at BioArts oversee an international bidding war of dramatic proportions in June? Or will the price of cloning prove to be too high for an untested market? Whether pet owners have $100k to spare or not, the auction will surely get people thinking—and arguing—about the ethics of pet cloning.

Why I Hate Meth Heads

by Emily Stephens

I don’t hate meth heads because they endanger entire neighborhoods with their toxic fumes. I don’t hate meth heads because they destroy the lives of abusers and their families. I don’t even hate meth heads because they made all the decent cold medicine disappear behind the Rx counter. I hate meth heads for one very intense, loathing, and entirely selfish reason… HAA—CHU!

I lived 27 years of my life oblivious to the hell of allergy sufferers. Now that I have settled down, bought a home in the desert, and started to grow roots, my world has turned upside-down. Juniper is my nemesis, and Albuquerque is surrounded by it. In an attempt to survive, I followed the same path millions of allergy suffers take: two months of Alavert (to no avail), two months of Claritin (complete waste of time), four months of Zyrtec (you’re joking, right?), and three months of a self-prescribed cocktail of Benadryl and Sudafed, all of which proved pointless. These “remedies” might as well have been sugar pills. So, I went out on a limb and tried the “alternative medicine” tract. I tried Chinese herbs and acupuncture. I even dreadlocked my hair, burned strange candles, and prayed to my living room papa-san chair (I mistook Wicca for wicker). HAA-CHU!

I investigated allergy shots, but was quickly rejected as an ineligible candidate. You see, to add salt to my wound, I discovered I am immunodeficient. When immune B cells and T cells are activated by an invader, they replicate into more antigen-fighting cells and something called long-lived memory cells. Long-lived memory cells are responsible for remembering exactly how the invader was destroyed, so the next time he comes around looking for some action—SMASH! WHAM! KABOOM!—long-lived memory cells knock him out of the picture. My immune system suffers from having “no anamnestic response,” or rather, no short-term memory. I lack the adaptive quality that healthy immune systems boast. My body cannot recall how to fight off the diseases and infections that it has already conquered. So, every winter I catch a cold, take an unusually long amount of time to get over it, and then quite often catch the same cold again a week or so later. This same scenario is what prevents allergy shots from working in my body. The allergen is injected, my B and T cells do a little dance, and then…HAA CHU!

One blessed day, Providence led me over-the-counter to something marvelous. Heralding angels rejoiced as the register tallied my bill, a $10.79 purchase of Drixoral. Schering-Plough Healthcare Products are the makers of Drixoral, an over-the-counter allergy and cold medicine that contains dexbrompheniramine (antihistamine) and pseudoephedrine (decongestant). Amidst the worst weeks of juniper season, I finally found relief. One pill allowed me to function in the world—albeit in a misty stupor. I was no longer sneezing. The irritated, itchy roof of my mouth went back to being unnoticed. My lungs also joined the land of the breathing, finding relief from asthma. Just like Moses and the Red Sea, my seemingly endless mucous parted, allowing my sinuses the forgotten sensation of inhalation.

All was fine and dandy until I took the last pill in my Drixoral package today. I stopped by Walmart’s local pharmacy on my way home from work and wasn’t worried that they were out of stock. I tried Walgreens—also out of stock, then another Walgreens, then another and another. Six stores later, I realized Drixoral no longer existed within Albuquerque—at least not in pharmacies (we have a rather large population of meth houses). The rumor circulating around town and beyond (my friend’s step-father is a pharmacist in St. George, UT) was that Drixoral was discontinued to prevent the illegal manufacturing of crystal methamphetamine.

A few startling quick facts about the people ruining my life:

1. One gram of their meth costs about $260, a price that has raised since last year’s $160 per gram…price gougers. Per pound, it costs $12,000 to $16,000 at the wholesale level.

2. It is a nationwide law that a valid I.D. and signature are required to buy cold and flu medications containing pseudoephedrine. Pharmaceutical companies compensated by introducing a string of new cold remedies containing phenylephrine instead, which can’t be used to make meth.

3. Some of the effects of meth abuse include: paranoia, brain damage, hallucinations, hypothermia, convulsions, cardiovascular collapse, and a condition called “tweaking.” Tweaking is when the abuser cannot sleep for days, is extremely irritable, and becomes violent without provocation.

4. A few of the warning signs there is a meth house near you include: odor of solvents, blacked out windows, activity late at night, iodine-stained kitchen or bathroom, and excessive trash. Cleaning up a meth lab can cost the government up to $10,000.

Had I been privy to the memo forecasting the removal of Drixoral from the market, I would have stashed a large supply—even at the risk of appearing like a junkie myself. Is it fair to take such a needed product off the market because of a handful of drug dealers and producers?

So, I took to my next weapon—the internet—and searched for Drixoral for hours (this is a matter of life or death, you realize). I found nothing on Scherling-Plough’s website (http://www.schering- plough.com/schering_plough/pc/allergy_respiratory.jsp) claiming they were taking the drug off the market, but there were no links to order the product either. I finally decided to bite the bullet and call Schering-Plough to get the low-down on Drixoral myself. Straight from the horse’s mouth: Drixoral will be off the market for one year as Scherling-Plough relocates their manufacturing plant. I made them promise they would not discontinue the product. We spit on our hands and pinky swore…well, as best as two people can do over the phone. They took an oath; a Bible was involved. I think I promised the pharma company one of my future children... But, at least I know Drixoral, my saving grace, will return.

I guess I don’t have to hate meth heads anymore…

Ethics of Branded vs. Generic Drugs

On May 15, 2008, an article in the Wall Street Journal reported that a United States appeals court upheld a lower-court ruling striking down patents for Lovenox, an anticoagulant manufactured by Sanofi-Aventis (http://online.wsj.com/article/SB121080852140493397.html). This may clear the way for generic competition.

When a pharmaceutical company discovers or develops a promising new compound, they apply for and receive patent approval, which provides for 17 years of patent protection and exclusivity. This gives them the sole right to sell the drug while the patent is in effect. However, as the patent nears expiration, other pharmaceutical companies are able to applications to the Food and Drug Administration to obtain approval to market generic versions of the brand-name drug.

The pharmaceutical companies claim that the period of market exclusivity enables them to recoup the cost of developing the new drug. However, pharmaceutical companies often try to extend the period of exclusivity by obtaining approval for their own generic version of the branded drug, which provides an additional 6-month marketing exclusitivity period. Also, they may try to obtain an extension on exclusivity by targeting special populations such as children.

The ethical dilemma raised here is how this marketing exclusivity for the pharmaceutical company affects the patients, those individuals with medical condition who need the drug. The availability of generic equivalents for brand-name drugs makes it easier for patients with low incomes or no health insurance to get the medications that they need. Very often, brand-name drugs are priced well beyond their means.

My mother had deep vein thrombosis and a pulmonary embolism 7 years ago and consequently has been on daily anticoagulation therapy ever since. She is at high risk for having another pulmonary embolism and approximately 30% of people who have pulmonary emboli die. When she was recently scheduled to have a hysterectomy, her hematologist recommended that she transition to Lovenox (enoxaparin, Sanofi-Aventis) during the week before her surgery and the week after the surgery. Subcutaneous Lovenox has a much shorter onset of action and half-life (12 hours) compared with the oral anticoagulant warfarin (4 to 5 days). So, this would enable her to receive anticoagulation therapy up to 12 hours before her surgery and again within 2 days after the surgery, reducing the amount of time that she'd be at risk for developing deep vein thrombosis or pulmonary embolism.

The real surprise came when my mother tried to fill her prescription for Lovenox. She is retired, but she does have prescription drug coverage. However, her co-payment for a 10-day supply of Lovenox injections was $900. That's right, $900. The insurance company was also paying $900. It turns out that Sanofi-Aventis does provide assistance for some patients who are unable to afford needed medication. However, when I downloaded the forms and helped my mother complete them, it turned out that her annual income was $1500 too much to qualify for assistance. So, she had to pay the $900 for the Lovenox. In her case, the risk was too great to go without the medication. However, now that she's had the surgery, she doesn't know how she's going to manage to pay her co-payment for all of the other related expenses--the hospital, the surgeon, the operating room, the anesthesiologist. She hadn't expected one medication to take all the money that she'd been setting aside in preparation for the surgery expenses.

So, I was pleased to read the news article about Sanofi-Aventis and to learn that generic versions of Lovenox might soon be available. Lower-priced generics will make it easier for patients like my mother to obtain the medication that they need for anticoagulation. Hopefully, fewer patients will have to take pause to consider whether or not the risk of dying is worth the price of the drug.

HRT: More Unpredictable than Hormones Themselves

by Leane Scoz

Hot flashes. Insomnia. Mood swings. Decreased sex drive. Women between the ages of 45 and 55 describe it as pure hell. Menopause is a natural biological process that all women are forced to endure at some point in their lives. But, what is natural about it? Almost all women experience symptoms of menopause. For some, however, the symptoms are severe with no relief in sight, and women look to their doctors for help.

Hormone Replacement Therapy (HRT) came into the picture as a safe treatment for menopausal symptoms in 1942 with the marketing of Premarin™, followed by other treatments such as Prempro™. These medications contain one or more synthetic female hormones, commonly known as estrogen and progesterone. Premarin holds the crown for being the most widely prescribed drug in the United States because of its effectiveness in making menopausal women happy again.

The Women's Health Initiative (WHI) was a national health study launched in 1991 during the heyday of HRT prescriptions. According to the study, the clinical trials were designed to test the effects of HRT, diet, and supplementation on prevention of heart disease, fractures, and breast and colorectal cancer. The 15-year project involved over 161,000 women ages 50-79, and is considered one of the most definitive, comprehensive programs of women's health research ever done in the United States. Participants in the WHI trials were randomly assigned hormone medication or placebo. However, the NIH halted the study early because the health risks participants experienced outweighed the health benefits. Women taking the hormones did see some benefits, but they greatly increased their risk for breast cancer, heart attacks, strokes, and blood clots.

Menopausal women and their physicians felt betrayed. How could something with such a long standing history as being the women's miracle menopause cure now be proven to be unsafe? The results of the study compelled many physicians and women to abandon HRT and try to come up with alternatives with little to no avail. Think about trying to explain to a menopausal woman in mid-hot flash that if she dresses in layers and refrains from caffeine and alcohol, she'll feel back to her pre-menopausal self in no time...hide the knives!

Now, a recent ABC News article reports that an international panel of experts are giving the green light for HRT again. This change of heart comes after researchers revealed that the WHI was flawed. Participants in the trials did not accurately represent the menopausal population, with the majority being relatively old and suffering from other conditions that all boosted risk. The panel has agreed that HRT is safe and effective for short term use in early menopause.

With all the swings HRT is going through, what’s a menopausal woman to do? Hopefully, women won't become too hot and bothered and lose sleep over their decision to use HRT for some sought after relief.

Medical Breakthrough or Monstrosity?

By Randy Hendrickson

“Scientists have begun blurring the line between human and animal by producing chimeras—a hybrid creature that's part human, part animal.”
Mary Ann Mott, National Geographic News


According to Reuters UK ( “Factbox: Human Fertilisation and Embryology Bill” ), controversial medical research innovations are being debated in Parliament’s House of Commons this week. The Human Fertilisation and Embryology Bill raises several interesting bioethical issues, one of which would allow the creation of human-animal hybrid embryos to be used for medical research.

Interspecies embryos would be created by taking a cell from a patient and inserting it into an enucleated animal ovum. An electric shock would fuse the two cells together allowing the formation of an embryo. Because the genetic material from the animal has been removed, the resulting embryo would be 99.9% human and an excellent model for medical research. The proposed legislation mandates that these embryos must be destroyed before 15 days, and they must not be implanted into the uterus of a woman or another animal.

The advantage of creating mixed-species embryos is that they can be a powerful research tool for developing stem cell models without the use of human eggs. Embryonic stem cells would be taken from the new hybrid embryo and injected into specialized human tissues, giving researchers insight on understanding the progression and possible treatment of medical conditions such as Alzheimer's disease, cystic fibrosis, Parkinson’s disease, diabetes, and other inheritable diseases. Stem cells could also be used to repair human tissue by allowing new tissue that is genetically matched to the individual to be cultivated for damaged body parts without the risk of rejection.

Scientists and researchers are excited about the medical possibilities that may unfold, and supporters of this bill are convinced that these techniques are “an inherently moral endeavor” that could eventually save millions of lives. There is, however, a great deal of public anxiety about the ethics of experimenting across species boundaries. Many critics find it unnatural and morally wrong to combine human and animal genetics. They also question the benefits of hybridization, claiming that there is no evidence that this will help cure diseases and that other research methods are more effective. They find it both misleading to the public and an abomination to nature. “There are other ways to advance medicine besides going into the strange, brave new world of chimeric animals.”

Even scientists are divided on this issue. Although there may seem to be medical advances to be gained from human-animal hybridization, we really need to make sure that these benefits outweigh the possible risks. In the words of William Cheshire, associate professor of neurology at the Mayo Clinic’s Jacksonville, Florida branch,

“We must be cautious not to violate the integrity of humanity or of animal life over which we have a stewardship responsibility. Research projects that create human-animal chimeras risk disturbing fragile ecosystems, endanger health, and affront species integrity.”




[Photo courtesy of goatboyfilms.com/.]

The Ethics Behind Drug Ads

By: Jenny Walters

Everyday, as we watch television, whether it is the home and garden or sports channel, we cannot help but be confronted with an infinite number of drug ads. In a recent article published in Time magazine entitled “Do Consumers Understand Drug Ads,” the author, Kate Pickert, discussed how the consumer perceives drug ads.

According to Pickert, drug makers spend nearly $5 billion a year on drugs ads; with every $1000 spent resulting in 24 new prescriptions.[1] From the Nasonex bee to the Lunesta butterfly, you cannot turn on the television without viewing a drug ad. However, this May 2008, during a House Commerce Committee meeting, lawmakers focused on “deceptive” drug ads produced by pharmaceutical companies such as Pfizer and Merck, and argued the need for tougher regulations.1 In addition, the U.S. Food and Drug Administration (FDA), which mandates and monitors the content of drug ads, met earlier last week to discuss the topic of the content of drug ads in detail.1

Pickert stated the aim of many drug ads is to: “leave you confused about the information.” According to the FDA, drug ads must present a “fair balance” of the benefits and risks of a drug. However, this “fair balance” is rarely seen; as pharmaceutical companies create drug ads to sell a product, not warn consumers of the risks of a product. Therefore, the risks and side effects portion of a drug ad is usually fast, complicated, and masked by visuals effects that distract the consumer from what is being said.1 In fact, many consumers find the risks and side effects portion of drug ads comical at times. A recent Saturday Night Live episode even poked fun at the drug ads style of the presenting risks and side effects in their skit about Annuale, a made up birth control pill.1

As public scrutiny grows, pharmaceutical companies continue with their marketing ventures and are now turning to medical device ads.1 In Nov 2007, Johnson & Johnson launched a new television ad for Cypher, “a drug-coated coronary stent, designed to prop open narrowed arteries.”1 Ads, such as the Cypher ad, target millions of consumers who lack the medical knowledge to make a decision on whether they require such a device.1 According to Pickert, the Cypher ad creates questions regarding the “social benefits of medical advertising.”

From my perspective, a nurse, a mother, a pharmaceutical employee, and a consumer, I can see all sides of the drug ad dispute. Drug ads can be helpful to consumers, as they do provide them with information they may have otherwise not been aware of. However, the confusion created and the blatant disguising of side effects of a drug, is of great concern for me. Although at times the drug ads may be comical, ultimately they show the need for pharmaceutical companies to promote their products, make money, and put the patient safety last. As stated above, the pharmaceutical companies are trying to sell products, not warn of the risks and side effects of the products.

[1] Pickert K. Do consumers understand drug ads? Time [serial online]. May 2008. Available at: http://www.time.com/time/printout/0,8816,1806946,00.html. Accessed on May 18, 2008.

Chemotherapy and Family Rights: A Canadian Crisis

What do you do when a child refuses chemotherapy?  That's the question causing an ethical stir in Ontario, with an 11-year old cancer patient at the center of the storm.

A boy with acute lymphoblastic leukemia was forced to begin his latest round of aggressive chemotherapy last week after being taken into custody by the Children's Aid Society of Hamilton.  Diagnosed with leukemia at age 7, the boy and his family had refused further chemotherapy when his illness returned in February after 12 cancer-free months.

The boy's father was evicted from McMaster Children's Hospital after reacting in anger when the CAS took the boy into custody for treatment.  After a two-day standoff during which the father was banned from the hospital, both parties reached an agreement to allow the boy to return home after his current round of chemotherapy.  The family plans to get other medical opinions before June, when a judge is set to revisit the case.

Prior to the agreement, family and other supporters held a vigil outside the boy's hospital window.  Authorities cannot release the boy's name under youth protection laws.

The boy previously underwent aggressive chemotherapy that left his skin covered with rashes and sores in his mouth.  He experienced the vomiting and bloating typical of chemotherapy treatment, and was unable to walk on his own.  It's no surprise, then, that February's news that the cancer had returned left the boy reeling.  This time, he spurned chemotherapy for natural remedies such as chelation therapy, vitamins, oregano, and green tea.

The boy, who suffers from fetal alcohol syndrome and is mildly intellectually delayed, was deemed incapable of making an informed treatment decision.  That's when the CAS stepped in, under the advice of leading doctors.

The controversy raises a series of ethical questions:

• Is an 11-year old capable of understanding the implications of refusing chemotherapy?

• Should organizations overrule parents in cases of life and death, as deemed by doctors?

• What about a patient's right to quality of life?

• The boy received chemotherapy for several years, and the cancer came back — how long until "enough is enough?"

• What is the government's role in personal medical decisions?

The debate will surely continue in the Canadian media and elsewhere.  In the meantime, all parties involved are surely hoping for better days ahead for the boy who tragically finds himself at the center of the storm.

To Vaccinate or Not to Vaccinate? That is the Question.

By Leane Scoz

My husband was talking to one of our good friends, Jason, on the telephone the other night. Jason and his wife are expecting their first child any day now. He has been calling us for advice over the last nine months since my husband and I are also new to parenthood. I was not paying much attention to the telephone conversation until I overheard my husband discussing the vaccine/thimerosal controversy and trying to reassure our friend that vaccinating his child is the right thing to do. I immediately began blurting out my ideas on the subject until my husband had to end the conversation to calm me down.

The next day, I received an email from Jason telling me to go to the following link:
http://www.comcast.net/data/fan/html/popup.html?v=740175135
After viewing the news video clip, I frantically typed an email response to him. My husband joked that I was wearing out the keys on the keyboard because I was typing with such aggression. Before I hit the send button, I stopped to think about what I was doing. I realized that our friend is a soon-to-be new parent who is afraid of harming his child. He is simply trying to figure out the right things to do while being over influenced by the media during the process. I erased the entire email I had just spent a half hour typing and started over. I decided to simply provide him with the following link and told him to read it at his convenience:
http://www.cdc.gov/vaccinesafety/concerns/thimerosal.htm

Since I currently work in the vaccine industry, it is no secret what side I am on concerning this controversial issue. My 10 month old son has received all of the recommended childhood vaccinations to date and will continue to receive the remainder of them. I would much rather know I am preventing diseases that could potentially kill my child by vaccinating him than to worry about something that has not been scientifically proven. However, I realize that these are my beliefs and my duty to my friend is to make sure he is educated on both sides of the issue to enable him to make the best decision for his child. Brainwashing him with my beliefs is not the answer and would probably cause even bigger concern for him.

I believe my friend represents most new parents and the fears they face when determining if vaccination will be beneficial to their child. In today’s society where the media plays such a large role in our lives, it is often difficult to decipher what is legitimate and correct.

The Centers for Disease Control and Prevention (CDC) estimates that 1 in 150 children in the United States develop Autism Spectrum Disorder (ASD). The diagnosis of childhood autism typically coincides with the recommended time for childhood vaccines, leading many to speculate that a connection exists between the two. Thimerosal, a preservative used in vaccines, has been targeted as the cause. According to the CDC, thimerosal has not been used as a preservative in routinely recommended childhood vaccines since 2001. However, it has had zero impact on the rate of ASD, and combined with the lack of a plausible biological mechanism linking thimerosal to ASD, the scientific community has rejected the link between the ASD and vaccines.

Case closed, right? Wrong. A federal court case worth billions of dollars is currently underway. It involves the parents of over 4,800 autistic children who are claiming vaccines caused their children to develop ASD.

Because I work in the vaccine industry, I have to believe that what I do everyday is helping people rather than harming them. However, I can not help wonder how I would feel if I were the parent of one of those 4,800 autistic children. The last thing a parent wants to do is put their child through any unnecessary pain, illness, or even death. When science can not provide us with an answer, the decision becomes a personal struggle that parents ultimately need to deal with on their own. Hopefully, parents, such as my friend Jason and his wife, can make an educated decision they are comfortable with and enjoy a healthy, happy lifestyle with their children.

Super Food or Frankenfood?

By Randy Hendrickson

A recent CBS News article (“Figuring Out What’s In Your Food--May 11, 2008) has pointed out that 53% of Americans will not buy genetically modified foods (http://www.cbsnews.com/stories/2008/05/11/eveningnews/main4086518.shtml?source=search_story).

Genetically modified foods are those food crops that have been unnaturally altered on a molecular level using recombinant DNA technology. The advantages of genetic modification include enhancing the crop’s resistance to pesticides and herbicides, its tolerance to drought or cold, as well as to heightening the nutritional value of the food. The foods most affected by genetic modification are soybeans, corn, rice, and canola oil.

Although the FDA and the biotech industry claim that genetically modified foods are safe, “substantial equivalents” of natural crops, the public is still very wary. Most Americans, however, are unaware of how extensive the use of genetically modified food really is. More than 60% of processed food products in US supermarkets contain genetically modified organisms. The reason people are unaware is that genetically modified ingredients are not listed on food labels.

Several serious ethical issues are at stake. How can people make a reasonable choice if they have no way of knowing which foods have been genetically altered? In addition, there are also concerns that these products are brought to market without adequate safety testing. According to Dr. Martin Teitel, executive director of the Council for Responsible Genetics, genetically modified foods are being rushed to market for financial reasons, not for scientific reasons, before a full safety profile can be completely established.

Dr. Teitel sums it up nicely:

“we are the unwitting and unwilling guinea pigs in the largest experiment in human history, involving our entire planet's ecosystem, food supply, and the health and very genetic makeup of its inhabitants.”

Europe, Japan, and Australia all have policies for labeling genetically modified foods, and according to a CBS News poll, a total of 87% of American consumers would like to see labeling of genetically modified ingredients on food packages sold in the United States, so that they too can make informed choices about this fundamental issue.

[Photo courtesy of "Achoo! The Blog." Available at www.achooallergy.com/blog/2007/08/. Accessed May 18, 2008.]

Healthy Volunteers?

In an article published in the January 7, 2008 issue of The New Yorker, columnist Carl Elliott sheds light on the ethics of clinical trials http://www.newyorker.com/reporting/2008/01/07/080107fa_fact_elliott


After new drugs have been tested in animals for safety and tolerability, initial clinical trials in humans are conducted. These Phase 1 trials assess the pharmacokinetic and pharmacodynamic characteristics of the study drug as well as assess its safety and tolerability in humans. Most often, Phase 1 trials are conducted using "healthy volunteers" with no concomitant diseases who are not taking any other medications. The reason for this approach is to avoid confounding; making it easier to determine possible side effects associated with the study drug.


Phase 1 trials may often involve frequent blood draws to determine the plasma concentration of the drug in the bloodstream, collection of urine and feces to determine the metabolism and excretion of the drug, and administration of the drug after fasting or a high-fat meal to assess whether food affects absorption of the drug. For some studies, procedures such as biopsies, endoscopies, or echocardiograms are performed. Therefore, the people who volunteer to participate in these studies are often confined to a hospital ward or inpatient facility for several days or up to several weeks. These participants receive monetary remuneration from the pharmaceutical company that sponsors the trial.

Because of the nature of these clinical trials, the pool of potential participants includes those who have the time and need the money. This means that the healthy volunteers in many phase 1 trials are made up of the unemployed, college students, contract workers, ex-cons, and young adults living on the margins.

Under these circumstances, many ethical dilemmas may arise:

• Are people volunteering to participate in clinical trials for altruistic reasons or are they only doing it for the money?
• Should volunteers in clinical trials be paid by the pharmaceutical companies? If so, how much?
• If the sites conducting the clinical trials are being paid by the pharmaceutical companies, can they be objective when determining who is eligible to enroll in a trial?
• Are "healthy volunteers" truly representative of the target population or even the general population?
• If individuals are participating in multiple trials, are the results from subsequent trials affected by study drugs taken in previous trials?
• Is it ethical to use people in clinical trials to study a drug that those same people will never be able to afford to take, if the need arises, because they cannot afford or are not eligible for health insurance?
• Are investigators so focused on the fees that they receive from the sponsor for enrolling more subjects that they forget the Hippocratic Oath? First, do no harm.
  

Dubie or not Dubie?

By, Emily Stephens

Legalizing marijuana is a hot topic in the United States. For Timothy Garon, age 56, it was a deadly one. The Washington state native and musician believed he contracted hepatitis C (HCV) from a dirty needle during his “speed freak” days of using street drugs as a teenager. Over the years, advanced HCV ravaged his liver, compelling him to join the long list of those needing liver transplants. This is a common scenario for people with advanced HCV. According to the CDC, 75 to 85 of every 100 infected persons with HCV might develop long-term infection, while 1 to 5 might die from the consequences of long-term infection (liver cancer or cirrhosis). More so, HCV is the leading cause for liver transplants[1]. After attempts to receive the organ transplant, Garon was repeatedly denied a new liver. Why?

Mary Jane, weed, fatty, dubie, laughing grass—whatever you want to call it. ‘Marijuana abstinence’ better be your motto, if you’re hoping to receive an organ transplant anytime soon. Due to the intense pain associated with HCV, Dr. Brad Roter prescribed medical cannabis, or marijuana, to lessen Garon’s nausea and abdominal pain as well as increase his appetite. Although medical marijuana was authorized under Washington state law in 1998[2], the street drug remains illegal on the federal level, and many organ transplant committees and individual hospitals who develop criteria for organ recipients view those who use the substance as ineligible[3].

This poses a complicated ethical question. Should prescribed medical marijuana users be denied life-saving organ transplants?

In retrospect, Dr. Brad Roter admitted he did not know it would be such a hurdle if Garon were to need a transplant[4]. To further confuse the situation, the UW Medical Center released the following statement, "Although medical marijuana may be an issue in rare cases, it is never the sole determinant in arriving at medical decisions about candidates for organ transplants, and whether a patient is listed. Patients with a reasonable chance of survival and a good outcome, given a variety of factors, are listed[4]." According to Garon’s girlfriend, Leisa Bueno, Garon had been drug free since 2001, when he was diagnosed with HCV. Since that time, Garon grew his own marijuana for medical purposes, and was even arrested for doing so in December of 2007[3].

As of April 25, 2008, in Washington State alone, there were over 200 registrants on the waiting list for a liver and only eight donors[5]. Nationwide statistics report nearly 17,000 registrants in line for a liver transplant and only 539 deceased donors[5]. Those are tough numbers to swallow whether or not you're high on the dope smoke.

Although criteria for candidacy on an organ waiting list is ultimately determined by organ transplant committees and individual hospitals (which often include surgeons, social workers, and nutritionists), the medical community generally accepts a fairly new standard called the Model for End-Stage Liver Disease (MELD). The formation of MELD has led to startling improvements in the determination process, including a decreased mortality rate and waiting time[6]. According to Mary T. Austin, MD, MPH, from Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues, “in 1999, the [Institute of Medicine; IOM] deemed that waiting time was a poor indicator of medical urgency and that rates of transplantation, illness severity, and waiting list mortality were much more meaningful. The IOM recommended that allocation of deceased donor livers could be improved by instituting a mechanism that favored disease severity and deemphasized patient waiting time.... The [MELD] was identified as potentially meeting these requirements[7]."

One of the non-disease-specific criteria for placement on the liver transplant waiting list is six months abstinence from alcohol and illicit drugs[8]. Additional considerations are taken into account: Does the recipient have other serious health issues? What are the chances they will return to abusing illicit drugs or alcohol after receiving a new liver? Where “prescribed marijuana” fits into this equation is uncertain. Dr. Robert Sade, Director of the Institute of Human Values in Health Care at the Medical University of South Carolina said, "Marijuana, unlike alcohol, has no direct effect on the liver. It is, however, a concern ... in that it's a potential indicator of an addictive personality[4]."

Two months after Garon began hospice, one of his doctors refused to put in his paperwork for transplant candidacy until he discontinued marijuana usage for six months. Then, understanding a six-month time span might outlast Garon, the hospital agreed to reconsider his case if he completed a 60-day drug-treatment program. Unfortunately, Garon never got the chance. His HCV was too far advanced. The hospital denied his placement on the list again, and he died one week later.

What does this mean for future transplant candidates? Will they be penalized for heeding their doctor’s suggestion to use marijuana medicinally? Should doctors fear the consequences of prescribing marijuana to patients, even when nothing else works to alleviate pain? Do doctors realize prescribing marijuana will nip their patients’ chances at organ donation in the bud? There needs to be formalized national criteria to determine the eligibility requirements; one that thoroughly addresses prescribed marijuana. These questions must be answered before the next victim of miscommunication falls prey to death by dubie.

[1] http://www.cdc.gov/NCIDOD/DISEASES/HEPATITIS/c/faq.htm#1a
[2] http://www.aclu-wa.org/detail.cfm?id=182
[3] http://ap.google.com/article/ALeqM5iiNTqWskznUXcmUi8fblN69gxNNAD90DG7400
[4] http://seattletimes.nwsource.com/html/health/2004389825_liver03m.html
[5] http://www.optn.org/latestData/rptData.asp
[6] Arch Surg. 2007; 142(11):1079–1085.
[7] http://www.medscape.com/viewarticle/566277
[8] http://www.ncbi.nlm.nih.gov/pubmed/9404965

Stem Cell Clinical Trials

Stem Cell Clinical Trials

By Michael Leshinski

The world of stem cell research has most recently made the news by entering the beginning stages of their first ever FDA approved clinical trials. The trials were supposed to begin by testing cells in humans with spinal cord injuries, but the FDA has decided to delay the testing without explanation. Although the duration of the delay is unknown, one can wonder what reasons supported its decision. It’s possible that safety precautions contributed to the delay, as the trials will set a precedent in the world of clinical studies. Or was the FDA pressured by conservative lobbyists who oppose the usage of stem cells? Ethical questions are raised all around in this instance. Is it ethical to harvest embryonic stem cells from fetal tissue if they can be used to treat disease and save lives? Is it ethical for lobbyists and PACs to persuade government agencies?

As a medical writer, I am here to provide an unbiased view and merely act as a relay point of information. Revealing my opinions about this subject would not only go against what I have learned, but also spawn a political debate which I am not interested in participating. I have adapted a policy just as the old saying says, ‘Never talk religion and politics’. Instead, I propose these questions to my fellow bio-ethicians. Think about what it takes to harvest stem cells. Then think about some of the possible diseases that can be fixed by its usage. It may or may not be easy to decide where you stand on the issue, but it is important that you think about it.

The Ethics of Malaria Prevention

by Randy Hendrickson

Dr. Susanna Dodgson, the Chair of the Biomedical Writing Department, is a woman with a mission. Her goal is high—the total elimination of malaria. She has traveled to Africa numerous times and has met with key policymakers and influencers. She has done a lot of work to spotlight this problem and bring it to the attention of people who can make a difference, both in Africa, which carries the heaviest burden of malaria, as well as in the United States. She started the Medical Journal of Therapeutics—Africa, several issues of which are devoted to malaria prevention and treatment. One of her latest efforts includes a video “Malaria: A Preventable Disease,” which is now available on You Tube (http://www.youtube.com/watch?v=18UH-bvMWpc).

Malaria is largely preventable, yet over one million Africans die from this disease each year. Prevention is largely achieved through vector control or reducing the rate of transmission of the deadly disease. One of main preventive measures is the use of indoor insecticide sprays and insecticide-treated bed nets and curtains.

These measures are often difficult to implement and quite costly, especially in the poorer countries of Africa. Starting in 2003, however, there was a big increase in funding for malaria prevention. For example, between 2003 and 2006, the Global Fund spent more than $1.7 billion on malaria prevention. There has been other government and corporate sponsorship of malaria prevention projects, creating a “net culture” that includes groups such as the Bill and Melinda Gates Foundation, the President’s Malaria Initiative, Roll Back Malaria, and others. Although these groups provide subsidized bed nets to vulnerable groups, resources are still scarce and current methods of implementation are insufficient (1).

The ethical question involved is how are these scarce resources for bed net protection to be distributed?

• The target groups who would benefit the most from bed nets are pregnant women and children under the age of 5 years. Pregnant women, especially primigravidae women, have the highest risk for infection, and as a result, they are at risk for anemia, low birth weight, premature delivery, and even maternal death (2,3). Morbidity and mortality are also very high young children; most of the 1 million Africans who die each year are children under 5 years of age (4). Clinical trials in the 1990s consistently showed a 20% decrease in childhood mortality from regular use of insecticidal-treated bed nets (5).
• Conversely, should resources for net protection go to all people community-wide, without any discrimination or inclusion criteria? Coverage of the most vulnerable pregnant women and children is good for these target groups, but it has little if any impact on the vector population (6), which is important for the overall long-term public health of the area. Clinical trials also showed that there is a “community effect” (similar to the herd effect from the use of vaccines) by using insecticidal-treated bed nets. In these trials, entire families were targeted, not only the most vulnerable population. The bed nets were shown to be effective in reducing the vector population, and the chances of being bitten by an infected mosquito were greatly reduced (7).
• Should the money be spent on education of the people and the supervision of control efforts? Although clinical studies have shown the effectiveness of bed nets against malaria, will individual communities be able to maintain the 75% coverage that is necessary to significantly impact disease transmission? Human behavior may be the missing factor in this equation (8). The nets have to be procured and distributed, people have to be taught how to properly use them, compliance should be monitored, and disease surveillance is required (9). Education of the people is a key element for success.

These are the ethical issues that government officials and policymakers are grappling with in dealing with resource allocation for the prevention of malaria, and there are no easy answers. The international community (i.e., WHO, United Nation’s Development Programme (UNDP), UNICEF, and the World Bank) is committed to reduce the mortality and morbidity from malaria, but there is still much to be done. People like Dr. Susanna Dodgson are bringing these issues to the forefront of public awareness by making it the focus of research, education, and academic collaboration.





1. Roberts L. Battling over bed nets. Science. 2007; 318(5850): 556-559.
2. Steketee RW, Wirima JJ, Slutsker L, Heymann DL, Breman JG: The problem of malaria and malaria control in pregnancy in sub-Saharan Africa. Am J Trop Med Hyg. 1996, 55:2-7.
3. Menendez C: Malaria during pregnancy. Curr Mol Med. 2006, 6:269-273.
4. Owusu-Agyei S, Awini E, Anto F, Mensah-Afful T, Adjuik M, Hodgson A, Afari E, et al. Assessing malaria control in the Kassena-Nankana district using the RBM tools. Malaria Journal. 2007; 6:103.
5. Roberts L. Battling over bed nets. Science. 2007; 318(5850): 556-559.
6. Kitua AY, Mboera L, Magesa SM, Maxwell CA, Curtis CF. The untapped potential of bed nets. Science. 2008; 319:900.
7. Roberts L. Battling over bed nets. Science. 2007; 318(5850): 556-559.
8. McCutchan TF. Beyond bed nets. Science. 2008; 319:33.
9. Roberts DR. Preventing malaria in endemic areas. BMJ. 2007; 335:1001-1002.

Ethical Dilemmas in Neonatal Intensive Care Nursing

By: Jenny Walters RN, BSN

In being a nurse, I have come across numerous ethical dilemmas. However, not until I began my career as a neonatal intensive case nurse, did I truly come face to face with such dilemmas.

Neonatal intensive care nursing involves the care of critically ill neonates. The majority of neonatal intensive care patients are premature neonates (those born less than 37 weeks gestation).[1] Caring for premature neonates was far from typical nursing. It involved dealing with the family as whole, not just the patient.

During my nursing career in the Neonatal Intensive Care Unit (NICU), many of the physicians and nurses would state: “We can save virtually every baby that is born, but should we be saving virtually every baby born.” When I was working in the NICU, we cared for premature neonates that were as young as 21 weeks gestations. Full term neonates are between 37-40 weeks gestation.1 However, the gestational age of the neonates is just an estimate. Therefore, the premature neonates we took care off could have been as young as 20 weeks gestation.

According to the March of Dimes: “Premature babies…who weigh less than 3 1/3 pounds are between 20 and 80 times more likely to develop cerebral palsy than full-term babies.”1 Cerebral palsy in a premature neonate develops from bleeding in the brain, which can damage the baby’s brain tissue; or from the development of periventricular leukomalacia, which is: “the destruction of nerves around the fluid-filled cavities (ventricles) in the brain.”1

Although, there is a high incidence of cerebral palsy in premature neonates, there is also a high incidence that premature neonates will grow up to live healthy lives. Knowing that my patients could plausibly go on to have healthy lives was what kept me doing what I loved; caring for critically ill neonates.

As my career progressed, I became accustom to dealing with highly sensitive and difficult ethical dilemmas. My patients were the children of loving parents; children whom these parents would have given their lives for. For that fact alone, my duty as a neonatal intensive care nurse was to care for my patients to my best of my abilities and to respect the wishes of their parents.

[1] March of Dimes. Cerebral palsy: quick reference: fact sheet. Available at: http://www.marchofdimes.com/professionals/14332_1208.asp. Accessed on 11 May 2008.

Thick Skin or Thick Ankles?

by Emily Stephens

As November 2008 approaches, politics is on everybody’s mind, particularly the Hillary vs. Obama democratic race. I’m a little behind the times, so it wasn’t until last Monday that I first heard commentators criticizing Hillary Clinton, not for her rhetoric, health plans, or foreign diplomatic agendas, but for her “tree trunk ankles.” Jokes about Hillary’s monstrous synovial hinge joints have spread faster than Britney-Spears one-liners across 24-hour news broadcasts, late-night tv and internet websites. In fact, Google “Hillary Clinton” and “ankles”, and you’ll come up with approximately 203,000 hits. While it is an entirely new and admittedly fascinating phenomenon to watch a woman run for the oval office, I find it nauseating that such a defaming and utterly ridiculous “cheap shot” keeps America laughing.

Although the term is not included within Webster’s Dictionary, The Urban Dictionary defines Hillary’s condition as “cankles”: “The area in affected female legs where the calf meets the foot in an abrupt, nontapering terminus; medical cause: adipose tissue surrounding the soleus tendon, probably congenital, worsened by weight gain and improved in appearance only by boots (1).”

We’ve all seen cankles, some of us have them, and most of us know someone who has them. Pop culture’s “ideal woman” rejects the look, and when applicable, goes to great lengths to hide them. It is rumored celebrity Jennifer Garner only poses for photographs that conceal her exposed, embarrassing cankles. Whether or not this is true remains unknown, but the stigma of such body parts remains disturbing. Since when did our politicians, who are commonly average-looking people to begin with, have to be physically attractive? If our prerequisite for election includes ‘supermodel,’ then we might as well say Heidi Klum’s Project Runway tagline, “Auf Wiedersehen,” to the greatest of them: Washington and Lincoln, just to name a few. If the corporeal is considered top criteria for presidential worthiness than how in the world did James Monroe with his butt chin, Grover Cleveland with his obesity, or Martin Van Buren (2) with his fly-away hair ever take office? Should the public react to McCain’s "chipmunk-looking" cheeks? Sure we might exaggerate certain body parts of political leaders in cartoons, but why aren't afternoon broadcasts dedicated to President Bush’s ears? Do male candidates receive the same kind of scrutiny as female?

In my opinion, this is blatant disrespect towards women’s bodies. I’m sure Senator Clinton is thick-skinned enough to brush off such inappropriate criticism, but one might question the subconscious effect this will have on her psyche. According to Hillary, "I am surprised at the way people seem to perceive me, and sometimes I read stories and hear things about me and I go 'ugh.' I wouldn't like her either. It's so unlike what I think I am or what my friends think I am (3)."

To be honest, the situation reminds me of elementary school arguments, when my intellect was so unsophisticated that I resorted to name calling and pointing out the physical imperfections of my enemies. Quoting Shallow Hal (2001),"She's got cankles! It's like the calf merged with the foot, [and] cut out the middleman.’ If we resort to that mentality, than Hillary could fairly argue the tree-trunk girth of her ankles actually provides her with a firm foundation all other politicians should envy.

Perhaps this entire situation could be rectified if Hillary refused to wear dresses, thus hiding her legs underneath pants? Others jokingly suggest that she uses her health care plan to surgically correct what mother nature intended. This poses a question. Can cosmetic surgery fix cankles? Dr. Robert Schwartz write’s within his private blog, “Some women are genetically predisposed to have more fat in their legs and ankle… We do this procedure [liposuction] all the time, and have had great success with it. But it’s not for everyone with cankles. If the problem is excess fat, liposuction can give your ankle the attractive, natural appearance you’re looking for…because ankles are mostly bone and muscle rather than skin and fat..it is also critical to avoid damaging the veins in the ankle. This means that if you opt for this procedure, you should definitely choose a board-certified plastic surgeon (4).”

However, he warns that in some cases, cankles aren’t caused by excess fat, but larger than normal bone structure or muscular calves. The condition could also be symptomatic swelling due to a medical condition such as diabetes. “All of these possibilities must be ruled out before considering ankle liposuction (4).”

Where does that leave us, barring major surgery?

To wear a skirt or not to wear a skirt? That is the question. What a sexist dilemma. All in all, I’d say these stereotypical jabs have exited the realm of politics and transgressed into gender bias. I am not alone in thinking this. Feminist blogger, Brigitte L. Nacos, discusses her repulsion that Carl Bernstein, the author of A Woman In Charge: The Life of Hillary Rodham Clinton, was disgusted by Hillary’s ‘thick ankles (5).” Robin Morgan , co-founder of The Women’s Media Center, writes,“This is not ‘Clinton hating,’ not ‘Hillary hating.’ This is sociopathic woman-hating. If it were about Jews, we would recognize it instantly as anti-Semitic propaganda; if about race, as KKK poison. Hell, PETA would go ballistic if such vomitous spew were directed at animals. Where is our sense of outrage—as citizens, voters, Americans? (6)”

I admit that I remain undecided in my vote for who should become president, Hillary, Obama, or McCain. But, one thing is for certain, cankles will hold no part in my resolution.

1. http://www.urbandictionary.com/define.php?term=cankles
2. Martin Van Buren courtesy of PNC Bank Archives
3. Marian Burros, Hillary Clinton Asks for Help in Finding a Softer Image, The New York Times, January 10, 1995.
4. http://www.rsplastic.com/archives/169
5. Hillary Bashing: It’s About Male Supremacy, Stupid. Blog by Brigitte L. Nacos.
http://www.reflectivepundit.com/reflectivepundit/2008/02/hillary-bashing.html
6. http://www.womensmediacenter.com/ex/020108.html