Nature nurtures debate on namesake

Josh Carter, over at the Bioethics.com blog, comments on the editorial in the April 10th issue of Nature, (subscription only. Joe quoted some but let me know if you need the full text) which uses news of a transgendered (but not transexual) pregnant and bearded woman to ask the age-old question, what is "natural" and whether "natural" is better than "un-natural."

What do you want to bet that the author prefers "natural" fibers for his clothes and "organic," when it comes to groceries? We know that the editorial board has opinions on the good and bad, since the cover of the April 3 issue in front of me has the headline, "Carbon emissions: it's worse than you thought."

Even though the question couldn't have been asked quite this way in the past, Nature asks one of the oldest philosophical questions. Unfortunately, they ask in a juvenile manner. In fact, they beg the question by stating that the approved purpose is to "enhance the human condition."

(As I commented on the Bioethics.com blog) The “natural” uses of medicine and science seek to discover and use our discoveries to encourage, enhance, and/or return to optimal what Aristotle called the “telos,” the “what it is meant to be.” For instance, a splint reduces pain and holds the limb in physiological position as it heals. Hip replacements, glasses and hearing aids aren't normally intended to give you the ability to jump higher or stronger, see with the sight of an eagle or hear a pin drop in the next county -- they are used in an attempt to return your functioning to "normal."

The most active debates in science today are actually discussions about the “nature” of the thing we are studying or manipulating. Is global climate change causing the Earth to heat up more than is “natural,” is it man-made (due to those carbon emissions), or cyclical, etc. Should there be regulation on abortions to for sex-selection or to choose for deafness? Who gets the resources to be the Six MillionTrillion Dollar Woman and why not allow men and women to demand that their limbs be cut off or that their faces be botoxed and surgeried into a human caricature that scares children?

Again, we see the problem with setting up the ethics hierarchy so that "autonomy" trumps "non-maleficence." "I want" ethics over "First, do no harm."

Is there good in the telos, or is there any standard for dividing funding and power in science and medicine? If there aren’t good and bad uses of science and medicine, then “Anything goes,” if you can get the financing, the power, or the ability to do it.

I forgot (a note on memory and humanity)

I know that you may not be able to tell, but I'm trying to make my blog posts shorter. So, I left some quotes out of this morning's post on memory. However, this quote from the Time Magazine article, "The Ethics of Erasing a Bad Memory" by Dr. Scott Haig, on human-ness needs to be repeated:

Much of what we read about brain science in the media today would have us believe that we're nothing more, really, than very fancy machines. And surely what we're learning about the physical brain is exciting and powerful — but thinking honestly, it remains so limited. We can trace the brain pathway of a drug "high," we can call it pleasure, but that tells us nothing about what so many people choose instead — deeper things that somehow beat out mere pleasure as the reasons for doing what we do. Those comforts — of ultimate meaning, virtue, peace and joy — have little to do with molecules.

Drugs, Sleep, Memory and Ethics

New information on the science of memory may one day finally tell me why I have a hard time remembering names and even faces, but I'll store a patient's potassium level without even trying. As with all science research, we'll have to decide whether and why the information we discover matters and how to use it.

Last night's post was on the bioethics questions in a television show dealing with a patient who asked for help forgetting a trauma - actually, the emotional memories, not the facts. A wide range of articles on memory research is the subject of yesterday's post at Bioethics.net. There are posts to articles and blog entries on old and new information on drugs that affect memory, and disorders of memory.

That post contains a link to this New York Times article (free registration required) on the significance of sleep and memories. (I love the title, "An Active, Purposeful Machine That Comes Out at Night to Play.") The same session at the American Society of Bioethics and Humanities conference that dealt with blunting the emotional memory of trauma also touched on the ethics of new medications that enable people to sleep less. The question asked was whether avoiding the need for sleep would allow time for more worthy pursuits - the question and answer period focused on what to consider a "worthy" activity. According to the NYT article, the question should be what is lost.

As is too often the case, science gives us some of the answers to our questions (those "power naps" are probably good for dealing with facts and later sleep appears to be useful for detecting patterns) and technology or means (propranolol, propofol, Provigil, etc.) to manipulate ourselves and our behavior, before we come to a consensus on the ethics - or even the ethical principles that apply - of using our knowledge.

The old saying "let's sleep on it" may have some measurable truth - and a lot of wisdom, after all.

Television Ethics: "Private Practice"

The TV show, "Private Practice," hasn't impressed me with its medical, social or psychiatric integrity. But, I found myself watching it tonight, October 24th, and was more impressed than usual. Tonight's show touches on a cutting-edge bioethics topic that was also mentioned at last week's American Society of Bioethics and Humanities.

Major Multiple Spoiler Alert!!! Don't read more if you've recorded the show to watch later.


(Let's forget the thread on the women who come in for their pelvic exam by the kid midwife - where the only exam the women are evidently getting is the actual *pelvic* exam. No eyes, ears, throat, lungs, breast or abdominal exam. My Family Physician, head-to-toe, cradle-to-grave soul can't bear it.)

(And we won't even ask the Mama in me how I feel about 13 year olds having sex. You might be surprised that I don't freak or judge, though, and pretty much treat the girls the same way that the lead doc does. The difference is that I go out of my way to explain to families when they first come to the office that I consider their child my patient in his or her own right and ask permission to treat without notifying - and, of course, without billing - them if the teen requests that I keep silent. I've always been able to convince the young person to turn to their parents for help, but manage to keep privileged information privileged as long as possible. As far as I know, I've only had one family leave my practice after I explained my policy.)

Okay, back to the cutting edge bioethics topic.

One of the guest characters asked the internal medicine doc for a medicine that helps patients forget.

Actually, the medicine, propanolol, will not help her forget. However, it can help some patients stop feeling the panic and other horrifying emotions that come after a near-death or traumatic event like a rape that causes "Post Traumatic Stress Disorder."

MSNBC had a review, here, about the treatment last year.


The technique can be used to blunt the emotional memory -- not the actual memory or physical damage -- of the traumatic event. Adrenaline or epinephrine is the "fight or flight" hormone or drug that is released when there is stress. It's what causes what I call "the near-car-wreck" feeling that we feel, well, when we nearly have a car wreck.

Epinephrine gives you a boost of energy, pumping sugar, cortisone and other hormones into the body, to allow that fight or flight response. Do you need to take off and escape or stand and battle with whatever it is that is threatening you? Epinephrine is also involved in stimulating the bone marrow to make blood and other organs to heal faster, too.

Unfortunately, sometimes the body makes epinephrine inappropriately, when there's no real danger or when the danger is not severe enough. When that happens, we call it a panic attack or an anxiety attack as people experience the physical and emotional symptoms that are associated with real danger. Their bodies are telling them that they are in danger, but there's no actual threat to confront. When it gets in the way of your life, it's a disorder. Long term panic and anxiety that can be related to a past trauma, and that sometimes causing a person to feel as though he's reliving the trauma, is called Post Traumatic Stress Disorder.

Propanolol is a "beta blocker" that blocks epinephrine and which we often use to treat hypertension and even panic attacks. If used during the time after a traumatic event in which the long-term memories are set in the brain and/or in conjunction with behavioral therapy, it appears that the memory is disconnected, "disassociated," from the emotions that the patient experienced during the trauma and during the flashbacks when the memory makes the patient feel as though he's reliving the event, later. The treatment of PTSD that seems to work best is behavioral therapy, teaching the patient to control his own body's reaction.

Some ethicists are concerned that we may blunt a necessary healing function of epinephrine and the other body and mind effects of the stress reaction. However, I think of the treatment of stress disorders in the same way that I think of treatment of pain. Pain may help us prevent injury and warn us of a threat to our health. But we treat pain that is out of proportion or that is not useful to protect us.