Sunday, January 30, 2022

Is Medical Marijuana Safe and Effective?

I am on the record in opposition of Ohio’s system for authorizing the use of medical marijuana.  While I am not an expert on the issue, my reading over several years has informed me that persuasive medical evidence of safety and efficacy – the legal and regulatory standard used for prescription drug approval -  is lacking for nearly all ‘approved’ uses of this drug.  And while it is true that there is some evidence that marijuana offers benefit in a very narrow range of medical conditions, the broad claim of efficacy for a panoply of illnesses is unfounded scientifically.  Champions of medical marijuana use should want, if not demand, that the drug is vetted and tested under the auspices of the Food and Drug Administration.  Wouldn’t you want to be assured of any drug’s safety and efficacy?  Should anecdotes of benefit or beliefs of benefit be sufficient to release a medication for general use?  Is this the standard that we use to approve drugs used to treat hypertension and cancer?

Beyond the lack of rigorous medical evidence, I strenuously object to legislatures commandeering the medial marijuana approval process.  The notion of politicians granting medical approval of a drug for an ever-enlarging list of ailments is preposterous.  Of course, such a process should be wholly under the control and authority of medical professionals and appropriate governmental agencies.  Not only are lawmakers unqualified for this task, but the political process is contaminated with conflicts of interests, business concerns, lobbying influences and upcoming elections.  For example, if a medical marijuana company wants to build a large dispensary in a certain district, might this make the legislator representing that district likely to vote in support of any medical marijuana measure?  

Marijuana - Panacea or Faith Healing?

Look how ridiculous the situation has become here in Ohio.  This past December the Ohio Senate passed a bill that aims to legalize medical marijuana for a patient whose condition may reasonably be expected to be relieved by the drug.  Think of that absurd language!   Doesn't this seem just a mite too broad?  Who defines what constitutes reasonable?  What if a patient or even a doctor reasonably expects that medical marijuana will be effective against acne or arthritis or asthma or hair loss?  Remember, even now there are folks who believe that ivermectin is effective against COVID-19.

This horse has left the barn and there is no turning back. How did we let this happen?  The political and economic forces who favor (read: stand to benefit from) expanded medical marijuana use outmaneuvered medical professionals and enjoyed strong public support from ordinary people who truly believe in the product’s promise of healing.  But belief in benefit should not be the standard used to determine safety and efficacy of medical drugs and devices.  Politicians should rank dead last or lower on the list of folks who should be in charge of drug approval.  




Sunday, January 23, 2022

Vaccination is Tyranny!

Thus far, to the best of my knowledge, I have dodged infection with the coronavirus.  I am up-to-date on the recommended vaccinations and have comported myself with caution.  However, I am not in a state of personal lockdown and I still enter area retail establishments to make personal purchases, although I am always masked.  Currently, I am sipping a sugar-free peppermint mocha in a very sparsely populated coffee shop.  I accept that public health experts might challenge my definition of cautious.  Indeed, I’m sure many of them wouldn’t step foot, let alone a toe, into a supermarket these days.

But the risks of catching the corona on my personal forays in the community pale next to the risks I face each week at work when I am in direct contact with several dozens of patients and staff.  The omicron variant spiked into the stratosphere here in Northeast Ohio, but thankfully it appears to be in a steady descent now. It does not seem that the vaccines and boosters protect us against omicron infections as much as they do against serious illnesses.

The percentage of Americans who have been vaccinated has plateaued.  Clearly, those who have not yet been vaccinated have no intention to do so.  Perhaps, some might decide that the vaccine is preferable to job loss. But many will walk away rather than succumb to what they perceive to be an assault on their personal freedom.

There is always a patient or two I see in the office each day who are unvaccinated. Being a seasoned professional, I inquire of them in a measured and neutral manner as to what their concerns are.  'The reasons span a wide spectrum ranging from ‘I don’t believe in it’, ‘they rushed it through’,  I’m already immune' or 'it’s not safe'.

Recently, I heard a more strident exhortation of vaccine antagonism.

‘I won’t let a tyrannical government tell me what to do!’

I reflected on this angry remark afterwards and thought it was possible to connect it back to the January 6th insurrection.  Many of those who stormed the Capitol that day likely felt that they were attacking tyranny in the same way that the colonists rose up against the British a few centuries ago. But, of course, the January 6th insurrectionists can never be fairly analogized with Paul Revere, Benjamin Franklin  or Thomas Paine.  The January 6th rioters were not seeking freedom but tried instead to dismantle our freedom as they joined together on their evil joyride over the cliff.

If only there were a vaccine for every illness.  However, we can see plainly that there are maladies out there that we are not able to prevent or treat.

Sunday, January 16, 2022

Gray Areas in Medical Ethics

While I may consider myself to be an ethical practitioner, I am in imperfect member of the genus, Homo, practicing medicine in an imperfect world.  I don’t commit Medicare fraud or lie to my patients.  When I commit an error, I admit it.  I often counsel patients against proceeding with endoscopic studies, because I don’t feel they are medically necessary.  I do my best to keep my patients’ interests as my paramount concern.

But the world of medicine doesn’t always have bright lines and borders to keep us confined to an ethical zone.  Physicians and ethicists argue over where to draw these boundaries.  What was regarded to be unethical 10 years ago has become standard medical operating procedure in many instances.  Consider how the field of reproductive medicine has evolved.  The definition of death has been relaxed in order to increase the human organ donor pool. We will surely see human cloning in our lifetime.  Medical ethics is not easy to define.

Community physicians like me must tread into the ethical gray area at times.  Do these indiscretions contaminate our personal integrity? 

Could Noah Webster Precisely Define Medical Ethics?

Imagine you are the physician in the following common scenarios. How would you respond? 

A 30-year-old comes to the office with nausea.  He insists that an upper endoscopy be performed so that he can be reassured that no serious issue is present.  I advise that the test result will likely be normal.  I offer a less invasive and safer x-ray examination, but he wants the Cadillac scope exam.  Do you acquiesce and arrange the requested scope test?

A 60-year-old comes to see me because she seeks antibiotics.  She has a cold and antibiotics are not medically indicated.  She rejects my explanation and is unconcerned about the risks of antibiotics.  She points out that her previous doctor, who recently retired, always gave her antibiotics a few times each year for the exact same symptoms, which she believed was responsible for her rapid recoveries.  Do you cave?

You are a gastroenterologist who is asked to place a feeding tube in a failing and demented nursing home patient. The primary physician has already recommended the tube to the family who have been told that we cannot ‘just let her starve’.  The family accepts this physician’s advice.  The gastroenterologist is highly skeptical that the individual will derive any medical benefit or comfort from the procedure, but he has been called in simply for his technical expertise, not to offer an opinion.  Do you keep mum and place the tube as ordered?

While the principles of medical ethics are firm, the landscape can be murky and it can be challenging to find the light among the shadows.  

Sunday, January 9, 2022

Tennis Star Djokovic Held Captive in Australia?

Should the Serbian government send in elite commandos for a stealth rescue?

If you are a political leader or a celebrity, and you’re looking for some media attention, here’s a method that works every time.  Simply flaunt the pesky  rules that the rest of us obey. And then get caught. Remember when Governor Gavin Newsom was photographed dining out at a posh restaurant in violation of the COVID-19 safety protocol that he imposed on Californians?  Such behaviors only reinforce the recognition that many entitled folks believe that rules apply to the hoi polloi, but not to them.

Presently, tennis superstar Novak Djokovic is being detained in Melbourne, Australia after his visa was cancelled upon his arrival. There will be a court hearing tomorrow that will rule if the government can proceed with deportation. Djokovic, whose ranking is number one on the planet, arrived to compete in the Australian Open, one of tennis’s four major tournaments.  Djokovic is keen to compete since a win there would grant him the record of the most wins in singles in major tennis tournaments. 

Djokovic May Soon Be Hoppin' Back to the Airport!

Djokovic, who apparently has not been vaccinated against COVID-19, arrived having received a medical exemption for declining vaccination.  The Australian government has very specific criteria for what constitutes a medical exemption.  While it is true that he was granted an exemption, the waiver was granted by groups who have ties to the tennis tournament.  In other words, the exemption personnel may have had more fidelity to the tournament than they did to adhering to public health rules and restrictions.  Djokovic apparently was granted a medical waiver on the basis of a positive COVID-19 PCR test result last month.  However, the government does not recognize this as an exception and communicated this to the Australian tennis authorities in November 2021.  

Presumably, the Australian federal government has primacy with regard to COVID-19 and border entry policies.

Now, of course, the issue has been internationalized with Djokovic supporters in Serbia and elsewhere claiming he is being held captive.  He is free to leave at any time.

The Australian citizenry is inflamed at the prospect that an elite athlete is angling for special treatment.

Based on my knowledge of the issue, I anticipate that deportation will be deemed  lawful.   Djokovic may expect special treatment, but he deserves the same treatment and outcome that the rest of us would receive.  After all, an athlete of his stature and accomplishment should understand why rules and fairness are so important.

Sunday, January 2, 2022

Looking Back on 2021. Time to Look Ahead.

2022 is here!  2021 has been an annus horribilis for America and the world.   We have simply not been able to vaccinate and boost ourselves free of the suffocating tentacles of an evolving coronavirus. Here in Ohio and elsewhere COVID-19 tests are endangered species.  Folks spend hours trolling around town hoping that a local pharmacy or a public library will receive a supply at the very moment he or she walks in.  My own inquiries have all yielded the same result – no tests available and no idea if and when they may arrive.

Did you watch the ball drop on New Year's Eve?

The pandemic, which in any earlier time in our history would likely have drawn us together, is cleaving the nation.  The day before writing this, I saw 2 patients who had elected to shun the vaccine.  I’ll spare readers their explanations which originated in the huge ‘science-free zone’ that tens of millions of Americans inhabit.  And earlier in the week, a medical professional who had been vaccinated expressed opposition to a vaccine mandate.  Her objection is that the government should not be able to force us to take such an action.  (Keep in mind that this individual and myself and millions of health care professionals are required to accept yearly influenza vaccines, TB testing and to be up to date with various routine vaccinations.)  I understand the personal freedom argument.  And I agree that we must be very cautious about granting the government excessive control over our individual decisions. Clearly, many private businesses and organizations favor a vaccine mandate as is their right. Others are concerned that a mandate would leave them short of workers after a mandate walk out.  I responded to my medical colleague that her argument that a mandate encroaches on her freedom is vulnerable.  I have no objection, I remarked, if she wishes to refuse a mammogram.  Such a decision only affects her health.  But an individual who declines to be vaccinated can affect the health of others.  These folks have rights also.  But I admit that there is nuance and a slippery slope potential here.

And the FDA and the CDC haven’t inspired much confidence with fumbling decisions and mixed messaging.  Who can blame folks for being confused and skeptical?  The CDC’s most recent iteration of quarantine and isolation policies has been roundly criticized - not by anti-vaxxers but by public health experts.  In fairness, the CDC's new and improved version is an acknowledgement that the prior policy of prioritizing public health over the economy and education was misguided and needed to be recalibrated. 

This past year has also laid bare our politics at its worst.  Comity and collaboration are out and hatred and revenge are in.  The mantra for many of our leaders and their constituents seems to be, I win if you lose, not an uplifting strategy.  And, a year ago the nation was treated to an actual insurrection!

Beyond the pandemic, inflation is surging, our southern border is in chaos and lawlessness and violence abound.  We are all horrified at the smash and grab episodes that are captured on video.

And internationally, our relations with China, Russia, Iran are all going swimmingly. 

Here’s to 2022!  Hoping and praying for a new mantra.  How ‘bout, If we both win, we all win?