"I think vampires are real. How do you know vampires don't exist? It says in the Torah that witches are real, so why not vampires?"
...
Can't argue with that...
Saturday, May 09, 2009
Thursday, April 30, 2009
Pet Peeve
It really annoys me when I'm walking down the street and some random guy (always non-Jewish) walking the other way will say "Shalom!" to me and then continue on their way. They don't mean it maliciously as far as I can tell, but it's offensive in the same way as walking up to a Native American and saying "How!" would be.
Wearing a yarmulkah doesn't make me an effing mascot, jerks.
Wearing a yarmulkah doesn't make me an effing mascot, jerks.
Monday, April 27, 2009
Picture God?
In response to Daas Hedyot's recent post, where he asks "What persona was your god?," he gave me pause to recall how I conceived of God as a child, and this is what I pictured:
I can't remember a time when I ever considered God to be any kind of person. Even as a child if I tried to picture God, I thought of a black misty cloud against a dark backdrop or of my standing before a focused yet endless expanse of white presence. God was the moral imperative that without words communicated approval or disappointment for my behavior.
In retrospect, I guess I had a different kind of picture than most people. This may be instructive.
I can't remember a time when I ever considered God to be any kind of person. Even as a child if I tried to picture God, I thought of a black misty cloud against a dark backdrop or of my standing before a focused yet endless expanse of white presence. God was the moral imperative that without words communicated approval or disappointment for my behavior.
In retrospect, I guess I had a different kind of picture than most people. This may be instructive.
Sunday, April 19, 2009
Nihil and Void
Sigh. Alright, we're here again pondering the meaning of life. I halfway hate myself when I think about these issues because I sound irritatingly like some angsty teenager, but in reality people don't typically figure it out to any real satisfaction, they just ignore it by embracing one distraction after another. Perhaps that's easier to do as an adult when there are more practical concerns (whether necessary or artificial) which can serve as distractions. But in any event this issue should bother people right down to their very being, whether they go to highschool or can drink alcohol legally.
Of course nobody really knows the answer but there are a two basic approaches: one, that there is no point and the only "goal" is to make yourself as fulfilling a life experience as you can - however you define that for yourself. Or two, there is a point and the ideal is to match your goals to be in proper accordance with that point - however you understand the point to be.
Obviously you can see the basic self-centered vs externally centered foci between the approaches. There's a value judgement there that makes (at least) me feel that selfish concerns should not be the ends of one's existence, but that hardly serves as a point of fact to base a conclusion on. I go back and forth on this issue - often several times a day. That is, when I'm not distracted. When I'm feeling idealistic and moralistic I find myself leaning towards there being a reason for existence - where what we do matters, where our choices and the effects of our choices matter beyond how they make us feel. In those times I feel encouraged to pursue an active course of bettering the world, fighting for causes, conscientiously intervening in things gone wrong.
But then there are other times when I think that everything I know and everyone who knows me will be gone and lost and long forgotten by some not-too-distant future time. So I feel fatalistic and disinclined to make an effort to change anything at all. Kohelet. Humanity is filled with the wretched, the poor, the liars, the hypocrites; persecuters and the persecuted - all destined to die after a few short years, why work yourself up about it? This has been the staus quo for virtually all of human history and there is little sign of it changing. I'm constantly amazed at how far we've gone and how we've survived so long when there is so many WRONGS in how people do things. Our public institutions reek of intrigue and scandals. Our private lives fill the newspapers with crime and senselessness. Civilization itself may just be a bubble waiting to burst. Is anything worth fighting for?
In the end I make the conscious decision to live as though there is a point. But in my heart the battle wages and I fear that the other side - the void of fatalism and selfish nihilism - may take the field.
Of course nobody really knows the answer but there are a two basic approaches: one, that there is no point and the only "goal" is to make yourself as fulfilling a life experience as you can - however you define that for yourself. Or two, there is a point and the ideal is to match your goals to be in proper accordance with that point - however you understand the point to be.
Obviously you can see the basic self-centered vs externally centered foci between the approaches. There's a value judgement there that makes (at least) me feel that selfish concerns should not be the ends of one's existence, but that hardly serves as a point of fact to base a conclusion on. I go back and forth on this issue - often several times a day. That is, when I'm not distracted. When I'm feeling idealistic and moralistic I find myself leaning towards there being a reason for existence - where what we do matters, where our choices and the effects of our choices matter beyond how they make us feel. In those times I feel encouraged to pursue an active course of bettering the world, fighting for causes, conscientiously intervening in things gone wrong.
But then there are other times when I think that everything I know and everyone who knows me will be gone and lost and long forgotten by some not-too-distant future time. So I feel fatalistic and disinclined to make an effort to change anything at all. Kohelet. Humanity is filled with the wretched, the poor, the liars, the hypocrites; persecuters and the persecuted - all destined to die after a few short years, why work yourself up about it? This has been the staus quo for virtually all of human history and there is little sign of it changing. I'm constantly amazed at how far we've gone and how we've survived so long when there is so many WRONGS in how people do things. Our public institutions reek of intrigue and scandals. Our private lives fill the newspapers with crime and senselessness. Civilization itself may just be a bubble waiting to burst. Is anything worth fighting for?
In the end I make the conscious decision to live as though there is a point. But in my heart the battle wages and I fear that the other side - the void of fatalism and selfish nihilism - may take the field.
Sunday, April 05, 2009
Friday, April 03, 2009
L'Chaim...
So I'm in the middle of a two-week stint of Geriatrics right now. The topics of the day invariably surround the most depressing parts of medical practice. We have the incurable chronic conditions, the terminally ill, the demented, the depressed, the disabled and the debilitated. How many times have I heard the term "health care proxy" this week? I can't even guess. Palliative care; "sedation therapy."
Which is more depressing - nursing homes or hospices? At nursing homes the residents are generally demented and seem to exist in a sad world of juice boxes, patronizing nursing staff and the pervasive smell of urine. A second childhood? Perhaps. More akin to a gentle warehouse where they wait for...y'know. At the hospice the patients are generally making the good faith effort to gradually complete their wretched existence which at the end revolves around their particular personal horror. Yet their families want them to die "with dignity." Ha. Dying with dignity is among the most mythic of all ideas. There is no dignity in death, folks. None at all.
Are these the successes or the failures of modern medicine? Thanks to modern medicine we've destroyed the previous strongholds of the Angel of Death. Infectious disease, once the major killer of humanity, has now largely fallen thanks to germ theory and antibiotics. Women dying in childbirth is today only a remnant of the merciless killer of a bygone era. What we are left with are the chronic conditions like heart disease, COPD, and cancer. We are so good at keeping people alive longer that more of them successfully make it to a state of debilitation and dementia. On the one hand, of course it is better that people live longer (and presumably better) lives today - but on the other hand, they weren't storehousing people in nursing homes and hospices in the past. Of course we are glad when a person survives an ordeal that would have easily taken them in a previous century, but we then all too likely send them on their way to a possibly worse ordeal before they take their final leave. Better? Depressing. The Angel of Death is less brazen today, but he makes up for it by being more sinister.
There is no mystery for why this is so. Evolution via natural selection is a great problem solver but it applies its solutions jealously only towards the primary goals of survival and procreation. The human body is incredibly complex and works amazingly well - but only for the first few decades of life. Y'know, the decades where the procreation and raising of young takes place. After the children are grown the elder generation no longer serves a much adaptive role. They are expendable. Natural selection stops working its problem solving magic on the likes of grandparents and soon enough the human body breaks apart on predictable fault lines. If the human body is like an automobile - modern medicine has largely cured the likes of a head-on collision, but after driving hundreds of thousands of miles even the best designed car will be totaled by an accumulation of wear and tear.
Ideally the purpose of medicine is to cure disease - not to let disease win. Yet palliative care is about letting the disease takes its natural course while treating the symptoms. Perhaps we need to recognize our limits since medicine today is still remarkably primitive in many ways, but palliation is still the real booby prize of medicine. The patients suffer less but they still die. There are no victories, only slightly less bitter defeats.
Which is more depressing - nursing homes or hospices? At nursing homes the residents are generally demented and seem to exist in a sad world of juice boxes, patronizing nursing staff and the pervasive smell of urine. A second childhood? Perhaps. More akin to a gentle warehouse where they wait for...y'know. At the hospice the patients are generally making the good faith effort to gradually complete their wretched existence which at the end revolves around their particular personal horror. Yet their families want them to die "with dignity." Ha. Dying with dignity is among the most mythic of all ideas. There is no dignity in death, folks. None at all.
Are these the successes or the failures of modern medicine? Thanks to modern medicine we've destroyed the previous strongholds of the Angel of Death. Infectious disease, once the major killer of humanity, has now largely fallen thanks to germ theory and antibiotics. Women dying in childbirth is today only a remnant of the merciless killer of a bygone era. What we are left with are the chronic conditions like heart disease, COPD, and cancer. We are so good at keeping people alive longer that more of them successfully make it to a state of debilitation and dementia. On the one hand, of course it is better that people live longer (and presumably better) lives today - but on the other hand, they weren't storehousing people in nursing homes and hospices in the past. Of course we are glad when a person survives an ordeal that would have easily taken them in a previous century, but we then all too likely send them on their way to a possibly worse ordeal before they take their final leave. Better? Depressing. The Angel of Death is less brazen today, but he makes up for it by being more sinister.
There is no mystery for why this is so. Evolution via natural selection is a great problem solver but it applies its solutions jealously only towards the primary goals of survival and procreation. The human body is incredibly complex and works amazingly well - but only for the first few decades of life. Y'know, the decades where the procreation and raising of young takes place. After the children are grown the elder generation no longer serves a much adaptive role. They are expendable. Natural selection stops working its problem solving magic on the likes of grandparents and soon enough the human body breaks apart on predictable fault lines. If the human body is like an automobile - modern medicine has largely cured the likes of a head-on collision, but after driving hundreds of thousands of miles even the best designed car will be totaled by an accumulation of wear and tear.
Ideally the purpose of medicine is to cure disease - not to let disease win. Yet palliative care is about letting the disease takes its natural course while treating the symptoms. Perhaps we need to recognize our limits since medicine today is still remarkably primitive in many ways, but palliation is still the real booby prize of medicine. The patients suffer less but they still die. There are no victories, only slightly less bitter defeats.
Sunday, March 15, 2009
Eye Opening...
'What was practicing general surgery like?'
"Horrible!! Absolutely horrible. The ER would call with "this old lady has non-specific belly pain...I'd like you to come lay hands on her?" As if my hands are magical. As if I can really tell what the hell's going on. The ER doc is just trying to cover his ass (which is necessary in a society where patients see a 'normal, expected complication' as an opportunity to get rich), so it makes my workload that much heavier. So, I got lots of these CYA calls. Also, I was oncall every 4th night. And sometimes that would increase if a member of our group was ill, or otherwise absent. The money was pathetic, especially for the amount of time you're available...I couldn't even have a glass of wine with dinner, for fear I may be called in. I wouldn't make promises to attend events, or meet other obligations (that may be more meaningful to my life and well-being), just in case I got called in...or happened to run late on a case. This is a big imposition on your life..
Basically, your life is unbalanced. You miss tons of things that are important to you. You go thru life sleepy and tired...chronically. Your health isn't optimal...and it's all for what? To be called 'a surgeon.' That will get old as your children begin acting out in school....or choose grandpa over you for comfort and snuggles. When they seem to not like you very much...and you feel excluded from their lives. When you have a mild, dull headache from lack of sleep (or some other vital ingredient to a healthy body), on that 1 day off you may have in 10. And, low and behold, if you get 2 consecutive days off....you try to make-up for lost time. Guess what? You *cannot* make up for lost time. So, do you really want to spend your life doing this? And if not, why torture yourself for a decade, give up your 20s/30s, when you could be building something more sustainable....mentally, and physically?
'Any advise for those who may be trying to decide on a specialty?'
Shouldn't students pursue something they'll enjoy rather than a choose based on lifestyle? I agree that you should do a medical specialty that you (think you'll) enjoy. But, how long will you enjoy a miserable lifestyle? Is the practice of 'that specialty which brings you joy' going to be *enough joy* to off-set the absence of life outside of work? Like seeing your kids play little league. Being there at your daughter's dance recital. Taking your kids to a puppet show in the middle of the week at the local library. Sleeping in late on Sunday morning, then going out to brunch, spur-of-the-moment with your wonderful family. Drinking until you're tipsy, and then having great sex with your spouse. Just having time for creative flow of energy, and silence to obtain inner peace!! These things may not be possible if you only get one day off a week...and you have a ton of basic life stuff to attend to. For the rest of your life...imagine 'not having enough time.'
Who runs your household? Grandma or mother-in-law? That may be better than a nanny, but it's still not ideal. A mom who's in her 30s - 40s is a lot more attentive, active, and better able to deal with toddlers/tweens than a grandma. Besides, Grandma has raised her kids...and now it's time for her to be a *Grandma.* It's one thing for Grandparents to be intricately involved, and to hire a nanny for supplemental support as needed. But, if they're raising your kids instead of you...you'll have to consider the consequences of that (for both you, your family, and your children).
Would you rather pay someone to be the Mommy while you're the doctor...or would you rather be home doing the mommy (or daddy) thing yourself? Would you rather have other kid's fathers who have time to coach flag-football on Saturday mornings teach your son how to throw a football, or otherwise be present as the male figure in your son's life....while you're at work being the 'greatest surgeon ever?' It's no wonder that so many old men end up saying "Rosebud" as they lay dying, alone, on their deathbed.
You'll need to nurture your marriage, or it won't last. People (including spouses) will only tolerate so much. Even if you think your wife is "happy staying at home"...no one gets married to be alone.
You need to be present while your kids are kids. In 12-15 years, they won't need so much of your time...and a large part of your influence over them (your parental guidance) is over.
Are surgeons so cool? Yes and no. The work is like no other. It's exhilarating when you can cut someone open, and fix the problem. It's easy to get an ego...which is almost a requirement if you want to survive the process of training. If you're to compete, and not become an emotional wreck....you shield yourself from criticism with an enormous ego. This translates to the rest of your life....and your personal relationships will become antagonistic. At times, the only thing in your life going as planned is...surgery. So you hold on to that. Surgeons are as diverse as the population. I'm sure there are some who get off on being a surgeon because everyone says "ooohhhh." But, most people are just as impressed when you say "I'm a doctor." Nothing special (or even distinctive) about being a surgeon to much of the population. So, who are you really trying to impress? Other doctors? Your partner? Yourself? And that ego, that desire for respect and accolades, keeps 'em coming to surgery....even if it's not the right career choice for them. That thought of 'surgeons are so cool.'
Criteria used to decide:I say, decide *overall* what's important to you...and find a way to make those things fit together. This may mean choosing "your second favorite medical/surgical specialty" instead of your dream specialty...if you want a *dream life* overall!!
"Horrible!! Absolutely horrible. The ER would call with "this old lady has non-specific belly pain...I'd like you to come lay hands on her?" As if my hands are magical. As if I can really tell what the hell's going on. The ER doc is just trying to cover his ass (which is necessary in a society where patients see a 'normal, expected complication' as an opportunity to get rich), so it makes my workload that much heavier. So, I got lots of these CYA calls. Also, I was oncall every 4th night. And sometimes that would increase if a member of our group was ill, or otherwise absent. The money was pathetic, especially for the amount of time you're available...I couldn't even have a glass of wine with dinner, for fear I may be called in. I wouldn't make promises to attend events, or meet other obligations (that may be more meaningful to my life and well-being), just in case I got called in...or happened to run late on a case. This is a big imposition on your life..
Basically, your life is unbalanced. You miss tons of things that are important to you. You go thru life sleepy and tired...chronically. Your health isn't optimal...and it's all for what? To be called 'a surgeon.' That will get old as your children begin acting out in school....or choose grandpa over you for comfort and snuggles. When they seem to not like you very much...and you feel excluded from their lives. When you have a mild, dull headache from lack of sleep (or some other vital ingredient to a healthy body), on that 1 day off you may have in 10. And, low and behold, if you get 2 consecutive days off....you try to make-up for lost time. Guess what? You *cannot* make up for lost time. So, do you really want to spend your life doing this? And if not, why torture yourself for a decade, give up your 20s/30s, when you could be building something more sustainable....mentally, and physically?
'Any advise for those who may be trying to decide on a specialty?'
Shouldn't students pursue something they'll enjoy rather than a choose based on lifestyle? I agree that you should do a medical specialty that you (think you'll) enjoy. But, how long will you enjoy a miserable lifestyle? Is the practice of 'that specialty which brings you joy' going to be *enough joy* to off-set the absence of life outside of work? Like seeing your kids play little league. Being there at your daughter's dance recital. Taking your kids to a puppet show in the middle of the week at the local library. Sleeping in late on Sunday morning, then going out to brunch, spur-of-the-moment with your wonderful family. Drinking until you're tipsy, and then having great sex with your spouse. Just having time for creative flow of energy, and silence to obtain inner peace!! These things may not be possible if you only get one day off a week...and you have a ton of basic life stuff to attend to. For the rest of your life...imagine 'not having enough time.'
Who runs your household? Grandma or mother-in-law? That may be better than a nanny, but it's still not ideal. A mom who's in her 30s - 40s is a lot more attentive, active, and better able to deal with toddlers/tweens than a grandma. Besides, Grandma has raised her kids...and now it's time for her to be a *Grandma.* It's one thing for Grandparents to be intricately involved, and to hire a nanny for supplemental support as needed. But, if they're raising your kids instead of you...you'll have to consider the consequences of that (for both you, your family, and your children).
Would you rather pay someone to be the Mommy while you're the doctor...or would you rather be home doing the mommy (or daddy) thing yourself? Would you rather have other kid's fathers who have time to coach flag-football on Saturday mornings teach your son how to throw a football, or otherwise be present as the male figure in your son's life....while you're at work being the 'greatest surgeon ever?' It's no wonder that so many old men end up saying "Rosebud" as they lay dying, alone, on their deathbed.
You'll need to nurture your marriage, or it won't last. People (including spouses) will only tolerate so much. Even if you think your wife is "happy staying at home"...no one gets married to be alone.
You need to be present while your kids are kids. In 12-15 years, they won't need so much of your time...and a large part of your influence over them (your parental guidance) is over.
Are surgeons so cool? Yes and no. The work is like no other. It's exhilarating when you can cut someone open, and fix the problem. It's easy to get an ego...which is almost a requirement if you want to survive the process of training. If you're to compete, and not become an emotional wreck....you shield yourself from criticism with an enormous ego. This translates to the rest of your life....and your personal relationships will become antagonistic. At times, the only thing in your life going as planned is...surgery. So you hold on to that. Surgeons are as diverse as the population. I'm sure there are some who get off on being a surgeon because everyone says "ooohhhh." But, most people are just as impressed when you say "I'm a doctor." Nothing special (or even distinctive) about being a surgeon to much of the population. So, who are you really trying to impress? Other doctors? Your partner? Yourself? And that ego, that desire for respect and accolades, keeps 'em coming to surgery....even if it's not the right career choice for them. That thought of 'surgeons are so cool.'
Criteria used to decide:I say, decide *overall* what's important to you...and find a way to make those things fit together. This may mean choosing "your second favorite medical/surgical specialty" instead of your dream specialty...if you want a *dream life* overall!!
Thursday, March 12, 2009
The Other Side of the Curtain
So I'm now three quarters through my surgery third-year clerkship [and what, 15 months until my MD? Yikes!] and I'm thinking maybe it isn't the field for me. Not that I don't think the surgeries aren't cool, they really are for the most part, but there's a lot of baggage that comes with a surgery practice that I'm less keen on. There's the time spent in clinic, the time rounding on patients, the notes, the forms, the dictation on the phone, the frequent (and frequently busy) nights on call, the fact that my days run easily 14, 15, 16.....27 hours long, blah blah blah. And this isn't just residency, it's pretty typical of what an attending needs to do in general surgery too. I'm not letting all that cloud the coolness of doing surgery itself, but is it worth it? The money would be decent, but the lifestyle sucks and the practice is only a shining prize under a pile of detritus. I really don't know if that prize is worth the substantial cost.
I sense in myself the perspective that I wouldn't want to live this way my whole life and I would easily end up in a sub-specialty like colon/rectal (which sounds bad, but is actually cool because I have a fondness for the digestive system - don't know why), but once there I'd have to still do plenty of clinic/office time just so I could perform my half-dozen specialty procedures which I fear would eventually bore me. How awful.
So now I'm peeking over the curtain and considering another field: Anesthesiology. It's chock full of procedures (which are my favorite), they get to play with some of the most powerful drugs known to man, virtually no clinic, call is generally more limited and when called it isn't to consult but to do a procedure (intubate/epidural/general anesthesia/what have you). Anesthesiologists can also have a much more varied practice where they can be in the OR, on the labor floor, and in the ER or ICU securing a difficult airway all in one day. People tend to not realize this, but anesthesiologists are critical care specialists (as would make sense since they put people into a state of respiratory arrest multiple times daily) and often run the codes at the bedside. Plus, an anesthesiologist's day is defined by shift parameters so that when a case in the OR is running late, the anesthesiologist is relieved by the night shift at six or seven pm and goes home to eat dinner with his/her family while the surgeons go on working late into the night. And to top it all off, the compensation for anesthesiology is great - typically even better than a general surgeon.
In addition, there's virtually no overhead for an anesthesiologist's practice (which equates into significant freedom of where to live and where to work), they also get to wear pajamas (scrubs) to work all day, and they get to potentially participate in the full range of surgical procedures - pediatrics, plastics, brains, hearts, trauma, etc. - without being pigeonholed in a given specialty. The residency is also shorter, the people tend to be more personable, and the training is far less malignant.
Sounds pretty good, eh?
Some concerns: Would I get bored sitting in the 'cockpit' watching vital signs during those long cases? Will I be jealous of the surgeons and down the line regret my decision? (I have the same worry mirrored that if I'm a surgeon would I regret not choosing anesthesia? Though general surgery residencies have a 20% attrition rate, with most residents leaving for anesthesia. Comparatively, leaving anesthesia for another field is rare.)
Do CRNAs pose a real threat to the practice of anesthesia as we know it? (I doubt it.) Will socialized medicine reign in America to the point that I'd have to fill out more red tape and work longer hours for less compensation? (Same concern I have for most of medicine.)
I sense in myself the perspective that I wouldn't want to live this way my whole life and I would easily end up in a sub-specialty like colon/rectal (which sounds bad, but is actually cool because I have a fondness for the digestive system - don't know why), but once there I'd have to still do plenty of clinic/office time just so I could perform my half-dozen specialty procedures which I fear would eventually bore me. How awful.
So now I'm peeking over the curtain and considering another field: Anesthesiology. It's chock full of procedures (which are my favorite), they get to play with some of the most powerful drugs known to man, virtually no clinic, call is generally more limited and when called it isn't to consult but to do a procedure (intubate/epidural/general anesthesia/what have you). Anesthesiologists can also have a much more varied practice where they can be in the OR, on the labor floor, and in the ER or ICU securing a difficult airway all in one day. People tend to not realize this, but anesthesiologists are critical care specialists (as would make sense since they put people into a state of respiratory arrest multiple times daily) and often run the codes at the bedside. Plus, an anesthesiologist's day is defined by shift parameters so that when a case in the OR is running late, the anesthesiologist is relieved by the night shift at six or seven pm and goes home to eat dinner with his/her family while the surgeons go on working late into the night. And to top it all off, the compensation for anesthesiology is great - typically even better than a general surgeon.
In addition, there's virtually no overhead for an anesthesiologist's practice (which equates into significant freedom of where to live and where to work), they also get to wear pajamas (scrubs) to work all day, and they get to potentially participate in the full range of surgical procedures - pediatrics, plastics, brains, hearts, trauma, etc. - without being pigeonholed in a given specialty. The residency is also shorter, the people tend to be more personable, and the training is far less malignant.
Sounds pretty good, eh?
Some concerns: Would I get bored sitting in the 'cockpit' watching vital signs during those long cases? Will I be jealous of the surgeons and down the line regret my decision? (I have the same worry mirrored that if I'm a surgeon would I regret not choosing anesthesia? Though general surgery residencies have a 20% attrition rate, with most residents leaving for anesthesia. Comparatively, leaving anesthesia for another field is rare.)
Do CRNAs pose a real threat to the practice of anesthesia as we know it? (I doubt it.) Will socialized medicine reign in America to the point that I'd have to fill out more red tape and work longer hours for less compensation? (Same concern I have for most of medicine.)
Sunday, February 22, 2009
Do You Know What You're Signing Up For?
As apparently due to the ever increasing demand for organ donations and the limited supply of poor saps with brain death and viable organs, the Organ Procurement and Transplantation Network and the United Network for Organ Sharing (known as OPTN/UNOS collectively, the non-profit group which determines national policy for organ donations) has lowered the bar on death as of July 2007. No longer is brain death the only standard by which organ harvesting may begin.
According to the new rules a suitable candidate for organ donation can consist of:
"1. A patient ... who has a nonrecoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for DCD [Donation after Cardiac Death].
2. Other conditions that may lead to consideration of DCD eligibility include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury."
The idea here being that once a patient is determined to be a good organ donating candidate (i.e. ventilator dependent and without likely hope of recovery), his or her doctor can (with agreement from the next of kin) switch off the ventilator, wait five minutes or so until the heart stops beating and then declare death. After which the body is taken to the OR by the organ retrieval team. But the key thing to understand is that the patient is not yet dead when the decision for organ donation is being determined!
As Dr. Keamy notes:
"For some of the pathophysiological states enumerated, this amounts to plucking the fruit off the vine shortly before it would fall anyway. But this list also includes people with advanced ALS like Stephen Hawking, who has lived in that "donation qualifying" state for two decades or so; there is no mention of brain function whatsoever in this formulation; lack of awareness is specifically not a necessary component for inclusion."
Additionally, one must recognize that this system sets an all too likely scenario where the doctor has a conflict of interest between his patient and the organs which will go to the patients' of others. He's flipping that switch on a schedule that may have nothing at all to do with the state of his patient's health status. The drugs doctors give at the end of life can be palliative but they can also double-edgedly be used euthanizing-ly. Plus, there are drugs that can be given for the sake of organs health which do nothing for the individual's length of life. For a person to become an organ donator while still alive is extremely dangerous territory. Because while we hope each physician will keep himself minding his patient's needs and only his patient's needs, organ donation can require massive coordination and it's doubtful he'd be operating in an "ethically pure" environment. Indeed, if he starts to care about the sake of those organs (as would be difficult for him not to), might he be operating at cross-purposes?
And last but not least, the Halachic implications are obvious. The person is not brain dead and is therefore NOT DEAD when the ventilator is turned off. At least according to US law, R' Moshe Tendler and HODS, that is. This method for organ donation would therefore be totally improper by those Halachic authorities which permit donation. It would in fact be murder. Though ironically, the Israeli Chief Rabbinate Council's test of "respiratory failure coupled with profound nonresponsiveness," which rejects the need to check for brain death may fit what OPTN/UNOS has decided.
Now, practically speaking, patients are pulled off of ventilators all the time even when brain death is not determined since that may have been the expressed will of the patient or the health care proxy. The secular legal precedent is already there many times over and if that's already accepted why shouldn't they schedule an organ harvest ahead of time to act upon death? Maybe this is a good call after all that will lead to more organs being available for those who need them. Maybe. For now though, adjusting the definition of death for the sake of organ donations gives me the willies.
According to the new rules a suitable candidate for organ donation can consist of:
"1. A patient ... who has a nonrecoverable and irreversible neurological injury resulting in ventilator dependency but not fulfilling brain death criteria may be a suitable candidate for DCD [Donation after Cardiac Death].
2. Other conditions that may lead to consideration of DCD eligibility include end stage musculoskeletal disease, pulmonary disease, and high spinal cord injury."
The idea here being that once a patient is determined to be a good organ donating candidate (i.e. ventilator dependent and without likely hope of recovery), his or her doctor can (with agreement from the next of kin) switch off the ventilator, wait five minutes or so until the heart stops beating and then declare death. After which the body is taken to the OR by the organ retrieval team. But the key thing to understand is that the patient is not yet dead when the decision for organ donation is being determined!
As Dr. Keamy notes:
"For some of the pathophysiological states enumerated, this amounts to plucking the fruit off the vine shortly before it would fall anyway. But this list also includes people with advanced ALS like Stephen Hawking, who has lived in that "donation qualifying" state for two decades or so; there is no mention of brain function whatsoever in this formulation; lack of awareness is specifically not a necessary component for inclusion."
Additionally, one must recognize that this system sets an all too likely scenario where the doctor has a conflict of interest between his patient and the organs which will go to the patients' of others. He's flipping that switch on a schedule that may have nothing at all to do with the state of his patient's health status. The drugs doctors give at the end of life can be palliative but they can also double-edgedly be used euthanizing-ly. Plus, there are drugs that can be given for the sake of organs health which do nothing for the individual's length of life. For a person to become an organ donator while still alive is extremely dangerous territory. Because while we hope each physician will keep himself minding his patient's needs and only his patient's needs, organ donation can require massive coordination and it's doubtful he'd be operating in an "ethically pure" environment. Indeed, if he starts to care about the sake of those organs (as would be difficult for him not to), might he be operating at cross-purposes?
And last but not least, the Halachic implications are obvious. The person is not brain dead and is therefore NOT DEAD when the ventilator is turned off. At least according to US law, R' Moshe Tendler and HODS, that is. This method for organ donation would therefore be totally improper by those Halachic authorities which permit donation. It would in fact be murder. Though ironically, the Israeli Chief Rabbinate Council's test of "respiratory failure coupled with profound nonresponsiveness," which rejects the need to check for brain death may fit what OPTN/UNOS has decided.
Now, practically speaking, patients are pulled off of ventilators all the time even when brain death is not determined since that may have been the expressed will of the patient or the health care proxy. The secular legal precedent is already there many times over and if that's already accepted why shouldn't they schedule an organ harvest ahead of time to act upon death? Maybe this is a good call after all that will lead to more organs being available for those who need them. Maybe. For now though, adjusting the definition of death for the sake of organ donations gives me the willies.
Sunday, February 01, 2009
Yesterday's Parsha
Exodus 13 (KJV):
6Seven days thou shalt eat unleavened bread, and in the seventh day shall be a feast to the LORD.
7Unleavened bread shall be eaten seven days; and there shall no leavened bread be seen with thee, neither shall there be leaven seen with thee in all thy quarters.
8And thou shalt shew thy son in that day, saying, This is done because of that which the LORD did unto me when I came forth out of Egypt.
9And it shall be for a sign unto thee upon thine hand, and for a memorial between thine eyes, that the LORD's law may be in thy mouth: for with a strong hand hath the LORD brought thee out of Egypt.
10Thou shalt therefore keep this ordinance in his season from year to year.
11And it shall be when the LORD shall bring thee into the land of the Canaanites, as he sware unto thee and to thy fathers, and shall give it thee,
12That thou shalt set apart unto the LORD all that openeth the matrix, and every firstling that cometh of a beast which thou hast; the males shall be the LORD's.
13And every firstling of an ass thou shalt redeem with a lamb; and if thou wilt not redeem it, then thou shalt break his neck: and all the firstborn of man among thy children shalt thou redeem.
14And it shall be when thy son asketh thee in time to come, saying, What is this? that thou shalt say unto him, By strength of hand the LORD brought us out from Egypt, from the house of bondage:
15And it came to pass, when Pharaoh would hardly let us go, that the LORD slew all the firstborn in the land of Egypt, both the firstborn of man, and the firstborn of beast: therefore I sacrifice to the LORD all that openeth the matrix, being males; but all the firstborn of my children I redeem.
16And it shall be for a token upon thine hand, and for frontlets between thine eyes: for by strength of hand the LORD brought us forth out of Egypt.
So we have eating matzah for seven days in order for it to be "a sign unto thee upon thine hand, and for a memorial between thine eyes" in order for when your son asks you what it's all about you can explain. And then we have redemption of the firstborn which is also given as "a token upon thine hand, and for frontlets between thine eyes" for the same co-generational exposure and explanation.
C'mon now, how do these verses imply leather boxes instead of simply figurative phrases describing a mnemonic device?
6Seven days thou shalt eat unleavened bread, and in the seventh day shall be a feast to the LORD.
7Unleavened bread shall be eaten seven days; and there shall no leavened bread be seen with thee, neither shall there be leaven seen with thee in all thy quarters.
8And thou shalt shew thy son in that day, saying, This is done because of that which the LORD did unto me when I came forth out of Egypt.
9And it shall be for a sign unto thee upon thine hand, and for a memorial between thine eyes, that the LORD's law may be in thy mouth: for with a strong hand hath the LORD brought thee out of Egypt.
10Thou shalt therefore keep this ordinance in his season from year to year.
11And it shall be when the LORD shall bring thee into the land of the Canaanites, as he sware unto thee and to thy fathers, and shall give it thee,
12That thou shalt set apart unto the LORD all that openeth the matrix, and every firstling that cometh of a beast which thou hast; the males shall be the LORD's.
13And every firstling of an ass thou shalt redeem with a lamb; and if thou wilt not redeem it, then thou shalt break his neck: and all the firstborn of man among thy children shalt thou redeem.
14And it shall be when thy son asketh thee in time to come, saying, What is this? that thou shalt say unto him, By strength of hand the LORD brought us out from Egypt, from the house of bondage:
15And it came to pass, when Pharaoh would hardly let us go, that the LORD slew all the firstborn in the land of Egypt, both the firstborn of man, and the firstborn of beast: therefore I sacrifice to the LORD all that openeth the matrix, being males; but all the firstborn of my children I redeem.
16And it shall be for a token upon thine hand, and for frontlets between thine eyes: for by strength of hand the LORD brought us forth out of Egypt.
So we have eating matzah for seven days in order for it to be "a sign unto thee upon thine hand, and for a memorial between thine eyes" in order for when your son asks you what it's all about you can explain. And then we have redemption of the firstborn which is also given as "a token upon thine hand, and for frontlets between thine eyes" for the same co-generational exposure and explanation.
C'mon now, how do these verses imply leather boxes instead of simply figurative phrases describing a mnemonic device?
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