Published in the NEJM last month was a study titled “Fibrinolysis or Primary PCI in ST-Elevation Myocardial Infarction”… or “the STREAM trial” to its friends. This is a largish (n = 939 + 943) and fairly well-designed randomised interventional trial comparing two treatment strategies for all-comers with STEMI who presented within 3 hours of symptom onset but could not get to primary PCI within one hour. The treatment arm was given tPA (tenecteplase) as soon as possible and then had delayed (6-24 hrs) PCI. The control arm got no tPA but got to primary PCI as soon as possible. The primary outcome was a composite of death, shock, CCF, or re-infarction at/within 30 days.

Interestingly, 36% of the tPA group required urgent rescue angioplasty due to failure of reperfusion with fibrinolysis (median time to PCI = 2.2 hrs). The patients who were given tPA and did reperfuse had a median time to PCI = 17 hrs. The primary PCI group had a median time to PCI = 178 mins, or close enough to 3 hrs.

They found no significant difference in primary outcome between the two groups. Rates of intracerebral haemorrhage were 1.0% vs 0.2% for the tPA and primary PCI groups respectively, and the need for CABG was 4.7% vs 2.1% for tPA vs PCI as well. Both differences were statistically significant given the power of the study.

This trial was funded by Boehringer Ingelheim, the manufacturer of tenecteplase, and while maintaining quite rigorous objectivity, the authors summary conclusion was that:

“…a strategic alignment of prehospital or early fibrinolysis and contemporary antithrombotic cotherapy coupled with timely coronary angiography resulted in effective reperfusion in patients with STEMI who presented within 3 hours after symptom onset and who could not undergo PCI within 1 hour after the first medical contact. However, early fibrinolysis was associated with a slightly increased risk of intracranial bleeding”.

 

Not an entirely unreasonable precis of the results, but I think I would probably portray the findings a little differently in light of the spectre of the “discussions” with my cardiologically inclined colleagues that will undoubtedly ensue when decisions have to be made about urgent transfer for PCI for a 3am STEMI patient versus early tPA at a smaller centre and delayed PCI.

A couple of points are worth noting before everyone jumps on the “tPAyyy and de-layyy” bandwagon (complete with satisfied smiles and holding of hands):

– There was no difference in primary (cardiac) outcome for the punters in each group.

– 36% of the tPA/delay group required urgent rescue PCI to achieve this equality.

– The tPA/delay group had a 5-fold increased risk of ICH.

– The tPA/delay group had a 2-fold increased requirement for CABG.

For me, the practical upshot of all of this is:

My remote STEMI patient has a 74% chance of the optimal outcome (minimum cardiac badness at 30 days), 5 times the risk of ICH, and twice the risk of needing a CABG if I choose to give then tPA and transfer them in a leisurely manner for PCI, rather than having them haul arse to the cath. lab. as soon as possible.

I am but a simple emergency doctor, a wandering vagrant, an illegal alien, if you will, in the ivory, monitored-bed-lined  tower of academic cardiology. But given the information above, call me demanding, but I’m going to be advocating transfer for primary PCI every time.

Interestingly, the median time to urgent primary PCI in this trial was 178 minutes, suggesting that the current consensus international guidelines for choosing early tPA over transport for PCI if the delay to PCI is > 90 minutes might be a little too conservative; the subjects in the urgent PCI arm of this trial had equivalent cardiac outcomes and a lesser adverse event rate (ICH, need for CABG) with a median PCI delay of 3 hours. The tricky question is still what to do with the STEMI patient who is 1-2 hours from your cath. lab… do you give them tPA pre-hospital (or pre-transfer from a smaller centre) aiming for a chance (significantly < 100%) at earlier reperfusion at the expense of a higher risk of bleeding, or transfer them urgently without thrombolysis, as this study suggests that we can expect equivalent benefit from just scooping and running to the cath. lab at least out to 3 hours.

In summary, one can still debate the merits of tPA vs no tPA if you can get to PCI in under 2-3 hours, but in light of the STREAM trial results, I think it is reasonably clear that even if you do opt for tPA, there is no evidential basis for intentionally delaying transfer for PCI as soon as possible.

The full text of the paper can be found here:      http://www.nejm.org/doi/full/10.1056/NEJMoa1301092

Advertisements
Posted by: Chris Cole | June 6, 2012

Transit of Venus 2012

I thought I’d toss up a few snapshots I took today from my front yard in Canberra, as Venus wandered across the face of the Sun from our point of view, something it does fairly rarely by the standards of a human lifetime. The transits come in pairs, 8 years apart, with the previous one occurring in 2004 and the next not due until 2117 (in December, if you want to leave your great great grandkids a reminder note).

This particular transit was visible during it’s entirety if you happened to be anywhere in roughly the Eastern half of Australia (the sandgropers missed the first bit, as it started before dawn for them) and you were either high enough to be above the cloud layer, or lucky enough to spot the Sun through a few fleeting gaps in the quite pervasive clouds.

I didn’t catch the beginning or ingress part of the transit because… well, I don’t do mornings, really… but I dragged myself from beneath my exceptionally comfy doona and managed to haul my telescope and camera out onto the front lawn by 1030hrs or so in order to see what I could see betwixt the clouds. At great personal peril (it was a toss-up between being frozen, or blown away Wizard of Oz style in the gale force winds) I eeked out a few reasonably clear shots when the clouds deigned to part now and then, with some of the results posted below. These are also on Facebook, but the size reduction involved on FB kind of munted a few of them up, especially the stacked image (the nice red one), so I thought I’d chuck them on here at higher resolution. (Having said that, I have no idea how badly WordPress will squish them, too…)

They were all taken with a Canon 450D at prime focus of a Celestron C8 (8-inch Schmidt-Cassegrain) telescope. This is an f/10 instrument, and some shots were taken “bare” at f/10 and some were taken with a f/6.3 focal length reducer in the light path. Exposures on the camera varied but typically I was using shutter speeds between 1/400 and 1/1,000 seconds and an ISO between 400 and 1600.  Being too impoverished to afford a H-alpha filter big enough to cover the aperture of my telescope, a $15 sheet of near-enough-is-good-enough filter material found on eBay did the trick, sticky-taped over the front end of the OTA. 🙂  Unfortunately, I couldn’t find the right sized T-ring/adapter to mate the camera to the optical back on the OTA, and so an extra degree of dodginess was added by way of me having to manually hold the camera up to the optical back and/or mount it on an independent tripod behind the telescope.

The first image is composited from a stack of 9 separate exposures taken fractions of a second apart, and the rest are all single exposures.

 

[NOTE:  Okay, so it apparently just chops off the right hand side of each image. Click on them to bring up the full-sized images…]

ImageImageImageImageImage

Posted by: Chris Cole | June 2, 2011

Set phasers to stun? MooooOOOOooo…!!

A story produced by the ABC’s “Four Corners” program, which aired on Monday evening, has caused something of a furore in the community regarding the ethical aspects of Australia’s exporting of live cattle to Indonesia. While many issues were raised, the central theme was the treatment of the animals at the abattoirs to which they were distributed once in Indonesia. Specifically targeted were the methods of restraint and slaughter employed in these abattoirs, and the amount of suffering and, in some cases, wanton abuse, endured by the cattle prior to their death.

Footage of abattoir workers cruelly kicking the cattle, and striking them repeatedly and viciously with blunt objects needs no further discussion. The people involved would benefit from some time tied to a post while someone else does exactly the same thing to them. I suspect this would be most instructive for them, and personally, I would be delighted to volunteer my time to help out.

Similarly, depiction of the methods used to secure the cattle for slaughter leaves no room for any sensible debate. Roping an animal’s legs and “assisting” it to slip over on a wet concrete slope, only to then struggle to keep it still, with a significant delay to actual slaughter, is fairly obviously not the best way to go about the job.

The more moot point* has been the ethical dilemma over which method of slaughter is the more humane: ritual slaughter as prescribed by some religions, or slaughter after stunning. The slaughter of warm furry animals is always going to be an emotive topic, but while a lot of the heated rhetoric prompted by the confronting images broadcast on Four Corners could be reasonably described as spur of the moment emotional backlash, there is a sensible and rational argument to be explored here, and what follows aims to achieve what I hope is a fair overview of what scant evidence there is in this field.

Ritual Slaughter of Animals

Several religions require their followers to adhere to a form of ritual slaughter of their livestock in order for the meat so obtained to be considered acceptable for human consumption. Among the three prevalent monotheistic religions of modern times, Judaism and Islam both still require ritual slaughter of livestock in order to render the meat “kosher” or “halal” respectively. The requirements of the kosher and halal production of meat were intended primarily to ensure the humane treatment of livestock in an era when a very sharp knife wielded very quickly by very skilled hands was without doubt the least torturous way to end an animal’s life. The prescribed requirements also extended to the treatment and upkeep of the animal throughout its life, well before the time of slaughter.

While fine details vary, the religiously prescribed ritual slaughter of livestock essentially mandates that the animal should be alive, well and conscious at the time of slaughter. The animal is then to be killed by way of a long, deep transverse incision through the soft tissues of the neck. This incision should be performed in one smooth motion, and done in such a manner as to ensure that both carotid arteries (which supply most of the blood to the brain) and both jugular veins (which drain most of the blood from the brain) as well as the trachea (windpipe) and usually the oesophagus are all completely severed. This is intended to deprive the brain of its blood supply as quickly as possible, thus rendering the animal unconscious in the shortest possible time.

Specific details can vary due to differences resulting from Jewish and Islamic divergence; one might consider it ironic that they share a common ancestor, and then diverged, evolving into quite distinct species of religion that nonetheless, and as any biologist might expect, retain several traits and characteristics in common. (Interestingly, to extend the biologic analogy further, both “species” quite enthusiastically compete for disputed shared territory, too). There is also some variation between countries and sub-sects of these religions due to subtlely different interpretations of their holy books.

The salient points regarding ritual slaughter are essentially that:

– It is intended to be a quick and humane method of slaughter.
– The animal is conscious at the time of slaughter.
– The animal is killed with a deep cut across the throat severing the blood vessels and trachea.

Ideal practice is for the animal to be contained and upright at the time the incision is made, and for the job to be done with an exceptionally sharp knife in one single, smooth and continuous motion. Unfortunately these conditions are not always met, and certainly they were nowhere to be seen in the abattoirs featured in the Four Corners story this week. The RSPCA scientist reviewing the footage supplied to Four Corners reported that of the 49 animals she had footage of, the average number of cuts made to do the job was 10, and some took up to 33 separate cuts with the knife to properly sever the important neck structures. All of the cattle slaughtered were also lying down on wet concrete with their legs roped and tractioned, rather than upright in a containment pen.

“Modern” / “Humane” Slaughter  …or… Stunning Before Slaughter

The standard of practice in Australia, and all developed nations where law is not dictated by religious dogma, is for livestock to be “stunned” immediately before they are slaughtered. Stunning can mean different things in different countries, and for different livestock species. For cattle, it is almost always the use of something called a captive bolt pistol. This is a pneumatically powered device that drives a blunt, rather heavy piece of metal (the bolt) against the skull of the animal. The bolt cannot leave the device, and has a restricted travel distance (hence “captive bolt”). It is featured as a somewhat novel murder weapon in the movie “No Country For Old Men”. It is not designed to penetrate the skull, and almost never does. Rather, the impact causes percussive injury to the brain (think of the world’s worst concussion from a very solid whack to the head) which is intended to render the animal immediately unconscious, and thus unaware and unable to feel any pain or distress when its throat is sliced open.

There is concern in some quarters regarding two aspects of percussive stunning. Firstly, that bolt stunning causes brain matter to enter the bloodstream (which it absolutely does; the literature is unanimous in this finding and so I have not bothered to include references), which is of concern if you live in an area where Bovine Spongiform Encephalopathy (BSE), otherwise known as mad cow disease, is endemic. Secondly, the possibility that bolt stunning does not actually render the animal insensate to pain and that it is therefore pointless. Advocates of the latter viewpoint with a religious bent go on to suggest that since stunning may not work anyway, then ritual slaughter is just as humane.

So what does science have to say on the subject? Unfortunately, not a whole hell of a lot. There has been very little formal research conducted to answer the question of whether stunning is more humane than non-stunned ritual slaughter. However, while the pickings are slim, let’s proceed with a round-up of the available evidence…

Evidence Quoted as Being In Favour of Ritual Slaughter

A colleague of mine brought an article to my attention, written in 2010 by one Karima Hamdan, entitled “Halal Hysteria”. It is a very eloquently written overview of the media hype surrounding this issue, with some discussion of evidence for and against the effectiveness of captive bolt stunning in cattle, and electrical stunning in both sheep and poultry. The author gets a little carried away at the end, reminding us that these animals are all Allah’s creatures, etc., but the main body of the article is a good summary and well-considered argument for why stunning might not be as humane as we’d like to think it is, and is a worthwhile read [1].

At the risk of raining on someone’s parade, bursting someone else’s bubble, or  otherwise buggering up a third person’s unspecified metaphorical device, it has to be said that the article’s discussion of captive bolt stunning in cattle may have taken a somewhat superficial tour of the available evidence. In the playground of “balance” in media reporting of contentious issues, opposing viewpoints are often represented as equally valid, out of all proportion to the reality of the situation, in order to seem politically correct and inclusive (yes, it’s all very warm and fuzzy), whereas in the real world of science we do our best to portray an accurate view of the evidence, however it falls. In this case, however, it may be fair to say that Karima has intentionally loaded the fat kid onto one end of the seesaw of balance, ignoring the conga line of skinny kids standing in the background.

Karima’s article, and almost every page on the web that involves a link to or quote from the scientific literature on this topic, references a paper published in a German veterinary journal in 1978 by Schulze, et al. [2]. Karima infers from the Schulze paper that:

1. Halal slaughter was not associated with any signs of pain.
2. Stunned animals showed EEG tracings consistent with perception of pain.

Okay. First things first. The 1978 paper by Schulze was a review article offering an overview largely of the political and regulatory environment pertaining to animal processing and slaughter in Germany at the time. The information regarding EEG findings in slaughtered animals was actually sourced from a short report by one of his colleagues, A.S. Hazem,  in 1977, based on research conducted by the Veterinary University of Hanover’s clinic for clawed/hoofed animals. The pertinent subset of data for captive bolt stunning of cattle was the result of studying precisely 15 animals (yes, n = 15), with 5 of them stunned, and 10 of them ritually slaughtered without stunning. The results were as follows:

– In ritually-slaughtered animals (n=10):
– No immediate change in EEG seen when the throat was cut.
– Flatline EEG was seen at <= 23 seconds in 7 of 10 animals. No comment is made on how long it took for the other 3 (presumably longer?).

– In bolt-stunned animals (n=5):
– All 5 animals showed EEG changes consistent with a seizure-like state.
– Flatline EEG was seen at <= 28 seconds in 4 out of 5 animals. Again, with no comment on the 5th animal.
– The author notes, several times, that the EEG changes seen in the stunned animals “…almost certainly eliminates a sense of pain”.

Karima infers that the ritual slaughter was not associated with any signs of pain, based on the fact that the (simplified) EEG trace did not change significantly when the animal’s throat was cut. It is unclear what changes one might expect to see in such an EEG trace due to pain, as such changes are quite subtle (though certainly detectable) even in human subjects with very complex EEG signal processing. It is questionable whether one would expect to see significant changes with the primitive equipment and processing available in 1978. Also, the wording of Schulze’s article is non-specific as to what happened a bit later than “immediately” but before the flatline EEG. Twenty three seconds is a long time when you’re standing around with your throat sliced open. Unfortunately the raw data from Hazem’s 1977 report is not readily available online, so making any more accurate interpretation is regrettably not possible at this time**.

The inference is also made that stunned animals showed EEG tracings consistent with pain, and this interpretation of the results is promulgated on other pro-Halal websites and blog entries [3]. The results reported by Schulze, and his own conclusion in the 1978 paper, simply do not support this assertion. Schulze concludes that:  “After captive bolt stunning most severe general disturbances (waves of 1-2 Hz) occurred in the EEG, which almost with certainty eliminates a sense of pain.” It is likely that a superficial reading of the paper, or a mis-translation from the original German, in which it was published, may be responsible and the error passed on a la Chinese whispers style, without anyone going back to check the paper for themselves. (Tell a lie, repeat the lie, the lie becomes the truth… as they say).

There was no other evidence in the scientific literature supporting the conclusion that ritual slaughter was less painful or more humane than stunning.

Evidence For What Happens To Stunned and Non-Stunned Cattle

Time to Physical Collapse

One good study published in 2010 addresses this question. Gregory et al. [4] had a look at what happened to cattle (n = 174) in a British abattoir that were ritually slaughtered without stunning. Note that this is in a modern facility where the cattle were kept upright in a containment device, subject to a single halal-compliant cut with a very sharp knife, and then released to stand or collapse as they pleased. The results were as follows:

– 14% of the animals collapsed, stood back up, and then collapsed again later.
– Average time to final collapse was 20 seconds.
– 8% of the animals took at least 60 seconds to collapse.
– A few animals took longer than 75 seconds to collapse.

These cattle did not have EEG electrodes connected to them, but I leave it to the reader to determine for themselves whether they think it likely that an animal that has had it’s neck sliced open, which collapses, and then is able to regain its feet for a period of time up to a minute or so, is unable to feel any pain or distress.

Bleeding Into The Airways

The same group published a paper back in 2008 looking at the prevalence of bleeding into the sliced open trachea, comparing the prevalence of blood in the trachea, the bronchi and the lower airways in animals that were stunned, or animals killed by ritual slaughter without stunning [5]. They found that:

– Stunned animals stopped breathing almost immediately.
– Blood in upper trachea:   Halal = 58% vs stunned = 21%
– Blood in bronchi:               Halal = 69% vs stunned = 31%
– Bloody froth in airways:      Halal = 19% vs stunned = 0%

(It was considered that bloody froth was indicative of the presence of blood in the distal or lower airways). The relevance here is that any extra fluid in one’s airways is extremely uncomfortable. Think about the last time you swallowed something and it went down “the wrong way”; even a small amount of saliva that has been aspirated (breathed in) will have you coughing madly for a while and it is most certainly not a pleasant experience***. Again, I leave it to you, the intrepid reader, to decide whether you think drowning in your own blood while you try to breathe for 20-60 seconds is a candidate for a Fun And Humane Ways To Spend Your Time award.

EEG Monitoring In Slaughtered Animals

The limited and poorly reported EEG data that was the subject of part of Schulze’s 1978 paper have been discussed above. Others have since explored the same avenue of investigation. In 1988 Daly et al. investigated the  time to loss of evoked EEG responses in cattle that were either stunned or ritually slaughtered [6]. This was a small study (n = 16) and the results were:

For stunned animals:
– 100% of stunned animals irreversibly lost evoked responses immediately.
– Average time from cutting of the neck to loss of all electrical activity was < 59 seconds.

For ritually slaughtered animals:
– Evoked responses were lost from 20 to 126 seconds (average 55 to 77 seconds) after cutting of the throat.
– Average time from cutting of the neck to loss of all electrical activity was 75 seconds.

Both visual and somatosensory evoked potentials were measured (somatosensory = touch/pain sensation from the body’s structures). The results indicate that the stunned animals lost the capacity for their brain to sense or react to any further sensory input (such as having one’s throat sliced open) after they were stunned. The ritually slaughtered animals demonstrated an ability to sense and react to sensory input (including pain) for an average of 77 seconds (somatosensory input). The time to flatlining of the EEG was also longer in the ritually slaughtered animals.

Gibson et al. looked at EEG changes in bolt-stunned cattle in 2009, and found that changes in cerebrocortical activity sufficient to produce insensibility occurred at 0-14 seconds after stunning [7]. The same group also found that EEG responses seen in animals ritually slaughtered, and thought to be due to noxious stimulus (i.e. the pain of having their necks sliced open) were absent in animals killed in the same way after captive bolt stunning [8, 9].

Conclusions

In determining whether ritual slaughter or stunning is more humane, the pivotal question is what and for how long does the animal feel before it dies. The available evidence, as detailed above, reflects the following:

– Both methods kill the animal in about the same time (as one might expect since exsanguination is the mode of death in both cases), though brain death (flat EEG) may occur faster in stunned animals.

– Ritually slaughtered animals continue to breathe as they begin to exsanguinate, whereas stunned animals do not. Ritually slaughtered animals consequently aspirate or inhale significant quantities of their own blood during their final minutes. This is almost certainly highly unpleasant.

– Highly sensitive EEG data demonstrates the persistence of the ability to sense and react to pain for an average of 77 seconds in ritually slaughtered animals. Stunned animals show no EEG evidence of evoked responses to physical stimuli of any sort, from the moment of stunning onwards.

– A significant proportion of ritually slaughtered animals are able to regain their feet after initial collapse, indicating ongoing brain function and consciousness. It is highly unlikely that they can stand up, yet not be aware of pain and distress.

While the origins of ritual slaughter as advocated by Judaism and Islam have their roots in a desire for the most humane treatment possible for livestock animals, modern insistence on such traditional slaughter methods have become, like so many other aspects of religious dogma and practice, inherited hand-me-downs from a more ignorant time. Such practices seem insisted upon predominantly (if not wholly) through a desire to adhere blindly to tradition, rather than for any practical or rational reason. Times have changed, and the best way of doing things millennia ago is not necessarily still the best way.

Attempts to mount a rational argument in favour of the ritual slaughter of cattle, while welcomed, are simply not supported (and are actively refuted) by the preponderance of available published, peer-reviewed evidence. The stunning of cattle immediately prior to slaughter clearly involves less suffering for the animal, and it is incumbent upon us as sentient fellow animals who understand all too well the nature of anxiety, pain and fear to do what we can to minimise that suffering. Ideally we could all become vegetarians overnight, but in a world where untold thousands of cattle will be killed every day for our benefit, the least we can do is make an effort to end their lives as swiftly and painlessly as possible.

—–

Addendum:   It should be noted that all of the above evidence and discussion thereof is based on the more or less perfect execution of ritual slaughter technique. That is, expert incision of the anterior neck structures with a very sharp knife by a skilled operator, in one smooth continuous motion, with the animal standing up and contained. i.e. the very best circumstances. Such conditions are not always met and, indeed, in the facilities seen in the Four Corners story, it appeared none of these conditions was met. The suffering of animals in such circumstances is almost certainly far worse than that noted in the arguments above.

Footnotes

* Yes folks, the primary meaning of “moot” is debatable, _not_ resolved or inconsequential.

** My minions are working on finding the original data. I’ll post an update when it’s available.

*** This is predicated on the assumption that at least some of you are as amazingly physiologically uncoordinated as I am and that you do, indeed, accidentally inhale your own body fluids and/or drinks now and then.

References

1. http://www.ummahpulse.com/2010/12/halal-hysteria.html

2. Schulze W, Schultze-Petzold H, Hazem AS, Gross R.  1978, “Experiments for the objectification of pain and consciousness during conventional (captive bolt stunning) and religiously mandated (“ritual cutting”) slaughter procedures for sheep and calves”, Deutsche Tierärztliche Wochenschrift 85(2) pp. 62-6.

(English translation:   http://www.mustaqim.co.uk/halalstudy.htm )

3. http://www.themodernreligion.com/misc/an/an_slaughter.htm

4. Gregory NG, Fielding HR, von Wenzlawowicz MV, von Holleben KV. 2010, “Time to collapse following slaughter without stunning in cattle”, Meat Sci. 85(1) pp. 66-9.

5. Gregory NG, Wenzlawowicz MV, Holleben KV. 2008, “Blood in the respiratory tract during slaughter with and without stunning in cattle”, Meat Sci. [Epub 10 Dec 08].

6. Daly CC, Kallweit E, Ellendorf F. 1988, “Cortical function in cattle during slaughter: conventional captive bolt stunning followed by exsanguination compared with shechita slaughter”, Vet.Rec. 122(14) pp. 325-9.

7. Gibson TJ, Johnson CB, Murrell JC, Mitchinson SL, Stafford KJ, Mellor DJ. 2009, “Electroencephalographic responses to concussive non-penetrative captive-bolt stunning in halothane-anaesthetised calves”, NZ Vet.J. 57(2) pp.90-5.

8. Gibson TJ, Johnson CB, Murrell JC, Mitchinson SL, Stafford KJ, Mellor DJ. 2009, “Amelioration of electroencephalographic responses to slaughter by non-penetrative captive-bolt stunning after ventral-neck incision in halothane-anaesthetised calves”, NZ Vet.J. 57(2) pp. 96-101.

9. Mellor DJ, Gibson TJ, Johnson CB. 2009, “A re-evaluation of the need to stun calves prior to slaughter by ventral-neck incision: an introductory review”, NZ Vet.J. 57(2) pp. 74-6.

Posted by: Chris Cole | September 22, 2010

Rationality in public policy-making… Wherefor art thou?

Euthanasia.

We do it to our pets, and other animals, when it is obvious that their potential quality of life, if actively prolonged or allowed to continue, is so poor that any benefit or enjoyment from it is considered far outweighed by the suffering they would endure for the time they continue to live. Most people would agree it is the humane thing to do in such circumstances. Why then, when it comes to human beings, is it suddenly so very difficult to apply the same rational approach? Why is it so hard to be humane to humans?

There are plenty of valid reasons why someone might oppose the idea of euthanasia, and plenty of valid reasons for supporting the concept. While debating sensibly the real pros and cons of euthanasia is a very worthwhile discussion to have, I’m not going to explore that here. Just at the moment, I’m more concerned with the types of arguments (or non-arguments) that people put forward in defense of their own position on the subject. Specifically the people who are entrusted to make decisions about such important matters for the rest of us. People who should know better. I’d like to explore the basis of their decision-making, because frankly, after sifting through a few recent news articles on the topic, I am somewhat concerned.

So, let’s have a look at some common “reasons” for opposing euthanasia. This may seem biased, but I’m afraid most of the worst arguments in such debates are to be found on the opposing side for this particular issue…

Arguments from Moral Authority

“Because it’s wrong!! Because…because… it just IS!!”, and any argument whatsoever that is based on the words “bible”, “christian”, “god”, “jesus”, “commandment” (or any other religious teaching or doctrine) do not constitute an adequate response. No. I’m sorry to have to break it to you, but purported authority derived from gut feelings, or instructions from imaginary friends in the sky simply don’t count. If you think they do, then perhaps it’s best you keep quiet while the grown-ups are talking. Better yet, while you’re keeping quiet, actually start thinking. It’s what your brain evolved to do. Honest.

Arguments from Fear-Of-Those-Who-Purport-Moral-Authority

This category mostly comprises politicians. To be fair, politicians are hamstrung by the unavoidable fact that their continued employment is dependent on catering to everybody; this unfortunately includes the ignorant, poorly educated and people with an imaginary friend in the sky. There is no intellectual means test applied to the right to vote. A direct consequence of this is that even a politician who can do the right thing and put aside their own personal views when deciding policy of this nature, will still do the wrong thing if it means retaining much-needed votes from the aforementioned sections of the populace.

Democracy is a wonderful ideal, however one should always remember that the majority will of the masses is by no means always the best thing for the masses. A clever fellow once said that it is rather important in a well-functioning society that a people should never fear their government, but a government should fear its people. This is a sensible and noble sentiment, however it should also be remembered that while important family decisions might be made inclusive of the opinions of all family members, it’s usually not a great idea to let the three-year-old decide the specifics of your new mortgage arrangements, or the wiring up of the house.

Arguments from It’s-Different-But-I-Can’t-Tell-You-Why

This is really a subset of the “Just because!” crowd who are able to bang a few more brain cells together but then stall en route. They might tell you that even though it’s not for religious reasons, they think euthanasia is still a flavour of murder, but they still can’t articulate a rational argument as to why it’s okay to put down your terminally ill dog, but not your grandmother. These people are victims of what Richard Dawkins has called, in a somewhat different context, the discontinuous mind. They perceive some vast but indefinable moral divide between humans and all other animals.

Kim Hames, the Minister for Health in Western Australia, has spouted a couple of superlative non-arguments for his decision not to support euthanasia when it is debated in parliament. Firstly, he says that while he supported the idea when he was previously working as a GP, he has changed his mind now because “…I just couldn’t myself be the one injecting the substance that takes somebody’s life and so my feelings have moved away.” So his personal opinion regarding whether he himself would like to be the one to push the button has changed, and that’s absolutely fine. No-one is asking him to. What he is quite blatantly overlooking, or more likely knowingly choosing to ignore (he is a medically qualified doctor, and in high public office; one presumes the man is not stupid), is the simple fact that his job is to make decisions that are in the best interest of the people he is sworn to serve, not to make decisions based on his own personal convictions. There is a rather important difference between the two perspectives. Secondly, he cites input from his constituents: “I talked to people in my electorate, particularly those with strong religious convictions, and they’ve convinced me that I won’t support this legislation.” Bowing to pressure of opinion from a group of people whose own conviction on the issue comes via the poorly documented mythology of bronze age desert goat-herders, regarding what an imaginary man in the sky allegedly thought we should or should not do, is surely a great basis for determining public policy? Isn’t it? No? Really?

Another favourite approach of politicians from both sides of the main political fence regarding this issue is to simply downplay and attempt to ignore it. This week, both the NSW Premier and the federal leader of the Opposition have said that it’s just not an important issue, and that parliament shouldn’t even be debating it. One has to wonder if such firm and summary dismissal of such a life-and-death topic is motivated by the need to distance themselves from having to publicly admit that their own standpoint on the issue has no rational basis, and they simply don’t want to look like total twats to the majority of the population who are, in fact, capable of both thinking for themselves and recognising it when others are evidently not doing so.

So, I wonder if it would be asking too much for our elected officials to do two things. Firstly, to set aside their own personal convictions and do what they are paid to do; make decisions about important matters of policy based on the best interests of their constituents. Secondly, to grow a pair, and have the fortitude to make policy that is in the best interests of the people, despite the objections of a minority upon whose votes they may very well depend, but who are very probably the least likely to base their vehemently held opinions on any rational assessment of the true pros and cons of the issue at stake.

Euthanasia. Present your reasons for supporting it. Present your reasons for opposing it. I don’t care. Just have reasons. Real ones. Please.

Posted by: Chris Cole | March 13, 2010

IVF… because… because… just BECAUSE, okay?

Our intrepid Federal Minister for Health, Nicola Roxon, has said that she would be personally very uncomfortable with allowing IVF parents to select the gender of their pyrex-spawned offspring, but has at least been sensible enough to make explicit the difference between her personal opinion, and any official government decision on the matter. (Which is something of a refreshing change, when compared to say, some of Tony Abbott’s comments and decisions as Federal Health Minister in times gone by).

Interestingly, though, while a non-medically trained, non-scientist politician is found making quite a reasonable and balanced comment on the proposal, it’s remarkable to see Professor Gab Kovacs, a “leading” IVF specialist (who really should know better) come out with the following pearls of wisdom:

“There are a small number of couples who are so determined they want a child of a particular sex, they’re prepared to go for the cost and the difficulty of IVF to get pregnant, rather than just do it naturally,” he said.

“I can’t see any reason why it should be forbidden. I’ve seen a number of couples who have maybe three or four children of one particular sex and they’re very keen on family balancing. That’s the type of couple that most often ask about sex selection.”

Indeed. So, firstly this guy is happy advocating the use of IVF when it is blatantly totally unnecessary, as the couple could conceive normally anyway. Secondly, he also sees it as perfectly reasonable that couples who already have three or four children should be able to make use of IVF to have yet another child, purely in order to balance out the set and presumably make use of all of those unluckily chosen baby gifts that turned out to be blue rather than pink, or vice versa.

Perhaps it’s a little much to expect a totally balanced opinion from someone who makes a very lucrative living by catering to such people (it’s a little hard to refer to them as patients in this context without being disingenuous), so in the interests of pointing out what should be blatantly obvious to anyone with a working brain, and doubly so to someone who allegedly holds a medical degree and higher specialist qualifications:

1. The world is already, by any reasonable measure, grossly overpopulated. Quite sensible arguments can be made for never using IVF, however strong humanitarian arguments can also be made for employing it in cases of infertility amenable to circumvention by this technology.

2. The use of such vast and expensive resources by couples who have no fertility problem purely because they want a child of a specific gender is egregiously self-indulgent and an obvious waste of time, expertise and money that could be used to alleviate real suffering.

3. Anyone who advocates the use of IVF for couples who already have “three or four” children, and especially if it’s ostensibly purely for “family balancing”, is demonstrating extremely poor judgement, on several counts.

If anyone can provide a sound ethical argument for (a) using IVF when no fertility problems are present, or (b) using IVF when a couple already has 3 or more children, I would be delighted to hear it.

Posted by: Chris Cole | January 24, 2010

“Toddler survives lethal snakebite”… Hmmm…

I suppose it could be argued I’m just just in a grumpy, pedantic mood after a run of night shifts, but after brief perusal of the Google News offerings this morning, I can’t help but wonder if I’m the only one who finds the headline “Toddler Survives Lethal Snakebite” inherently oxymoronic and well, just plain dumb? “Venomous” snakebite, perhaps. “Potentially lethal” snakebite, maybe. Possibly there’s a “two-syllable rule” for headlines at The Age, so as not to tax the linguistic skills of their target readership? Who knows. The article in question can be found here:

http://news.theage.com.au/breaking-news-national/toddler-survives-lethal-snake-bite-20100123-mrog.html

Perhaps we can beatify, canonise, or hey, even raise to messiah-hood the toddler in question. After all, he’s come back from the dead?

Posted by: Chris Cole | June 19, 2009

Toasted by taser…

A 39 year old Queensland man has been zapped to death by Police, after assaulting a neighbour, and threatening attending Police officers with an iron bar, broken glass, and full frontal nudity. Perhaps it was the iron bar, perhaps it was the glass… but perhaps the unrestrained wedding tackle of a ranting, agitated grown man was just too much for them to take. Whatever the cause, the ill-fated man was subjected to an unknown number of shocks from a Police taser. Initial reports suggested the weapon may have been discharged three times, however later statements have hinted that the taser was discharged 28 times, but it is unclear how many of those shocks were actually delivered to the fool idiot assailant “victim” before he promptly dropped dead. There was an enthusiastic attempt to resuscitate the gentleman but, for better or worse, he had become an irreversibly crispy critter.

Some commentators have lamented that “It didn’t have to be so!! They could have talked him down”, and so on… Yes… and they could have patted his head and given him fluffy bunny slippers, too. This guy was violently aggressive, had already assaulted one civilian, and was actively threatening Police with various nasty bits of hardware. The alternative was to shoot him. But they didn’t. They warned him, threatened him with the taser, and then when he continued to advance, they zapped him. Maybe they zapped him once… maybe they zapped him 20 times. It’s rather irrelevant. It was an appropriate response to the situation. There is a limit to the degree to which society can protect dickheads from their own stupidity.

So is the taser evil? Is “non-lethal force” a misnomer when applied to this newly acquired facet of the Police arsenal? The company that manufactures and sells the model of taser used by the QLD Police Service, Taser International

TASER model used by QLD Police

TASER model used by QLD Police

, has made a statement refuting Amnesty International claims that on the order of 300 deaths have been related to taser use worldwide. The company makes the point that no coroner or medical examiner has ever handed down a finding that a taser was the cause of anyone’s death. So who do we believe? Well, both… and again, it doesn’t really matter. While legally prudent, the suggestion that tasers have not contributed to any deaths is clearly a large crock of steaming poo. Someone, somewhere, is obviously going to have some pre-existing condition, or certain substances on board (think amphetamines and their relatives) that predispose them to having a not-so-insignificant probability of some interesting dysrhythmias when some nice Policeman decides to settle a bet with his mates and see if he really can make someone glow in the dark. In short, taser enough people, and someone is going to die. For argument’s sake let’s say that 1 in 1,000 people subjected to a good stern tasering will cark it. In fact let’s be terribly pessimistic and assume that 1 in 100 taserees will earn a ticket to the morgue. Is that cause for concern? When faced with this question, I feel it’s instructive to consider the alternative… If the Police did not have tasers as an option, what would they do in a similar situation? They would shoot the assailant. With bullets. From a gun. If the Police shoot 100 people somewhere in their torso from close range with a 9mm pistol, how many do you think might die? Perhaps more than just one? Hmmmm.

Tasers are a sensible option for Police confronted by violent dickheads who refuse to back down when given appropriate warning. Yes they are dangerous, but not as dangerous as the alternative response, which is the discharging of a firearm. I really REALLY would not like to be on the receiving end of a taser… but given the choice of that or being shot by a 9mm semi-automatic pistol… zap away, baby.

Posted by: Chris Cole | June 6, 2009

Perhaps the BCA is more self-aware than we thought?

It appears that while they are willing to sue science writers for making perfectly true assertions about their so-called profession, the British Chiropractic Association is otherwise quite open about admitting that their practitioners are certainly not health professionals…

Tacit admission? Separate headings for Chriropractors and actual Health-Care Professionals.

Tacit admission? Separate headings for Chiropractors and actual Health-Care Professionals.

Posted by: Chris Cole | May 16, 2009

Lawyers and the scientifically retarded join forces…

I suppose by now I should really stop being surprised by the degree of obtuseness and idiocy displayed on a regular basis by some of my fellow human beings, but sometimes… well… you just have to sit back and admire the spectacle of a complete and utter lack of rationality and logic when it’s elevated to levels one might have hoped were simply unattainable. And this week, via the works of the good people of the British Chiropractic Association and aided and abetted by the legal machinations of the English civil tort system, we are afforded ringside seats to a travesty of natural justice, and an insult to the sane and sensible everywhere.

Simon Singh, a mathematician and well-known UK author (Fermat’s Last Theorem, The Code Book, Big Bang, the list goes on) and television documentary producer, is currently being sued for libel by the British Chiropractic Association (BCA) because… well, because he truthfully stated in a newspaper article that claims the BCA had made regarding the use of chiropractic to treat certain medical conditions in children were utter crap, and the BCA were not very happy about it. To be somewhat more accurate, Simon Singh actually called the claims “bogus” and was generally far more polite than I would have been, and indeed intend, shortly, to be. Rather than just get all grumpy, take their bat and ball and storm off home, the BCA decided to go next door to their uncle the lawyer, and bring him back to the site of the dispute, armed with a much bigger cricket bat and a not-at-all veiled threat about using it, if Simon didn’t publicly retract the terrible things he had said about their precious quackery… er, delusions… um, preying on the gullible… oh, “profession”… yes, that must have been the word I was looking for.

Simon’s article can be found here: http://svetlana14s.narod.ru/Simon_Singhs_silenced_paper.html

The BCA brochure in question is here:
http://web.archive.org/web/20070206003656/http://www.chiropractic-uk.co.uk/gfx/uploads/textbox/Happy+families.pdf

Ignoring the more nebulous waffle found in the brochure, let’s focus on two of the specific claims made therein, namely that there is evidence that chiropractic is effective in treating asthma, and recurrent infections, especially otitis media (middle ear infections) in children. Demonstrating that their knowledge of the law regarding false advertising far outstrips their knowledge of science, medicine or pathophysiology, the BCA is careful to word their claim as “There is evidence to show that chiropractic care has helped children with…” these conditions. From a legal perspective this could be construed to mean anything from say a third hand story that one child somewhere, who happens to have asthma, burped less often one day in twenty and had been subjected to a chiropractic treatment at some point… to something more robust such as that a large randomised controlled trial has shown that a specific chiropractic intervention cures asthma as measured by objective lung function tests in a certain percentage of children. (I leave the reader to guess for themselves towards which end of this spectrum of possibilities the truth lies). It is important to realise the wording is loose enough to allow a lot of latitude in one’s interpretation of the statement. There is no assertion about the quality of evidence involved, the existence or not of conflicting evidence, or that the non-quantified or even qualitatively described “help” had anything to do with the illness in question. Cleverly constructed legalese aside, however, does anyone of reasonable intelligence doubt for a second that the implied meaning of the sentence is essentially “We have evidence that chiropractic is an effective treatment for…” these conditions??

So why would Simon Singh suggest that such claims are bogus, unfounded and generally just plain not true? Because he’s right. Such claims are, by any reasonable standard, patently false. Chiropractic suffers, like many so-called alternative therapies, from the fact that there is very little good quality research done in their field, and that what decent research is done consistently fails to support their most treasured claims. A recent systematic review, published in one of their own journals, concludes that the quality of evidence for the role of chiropractic treatments in all paediatric conditions in which it is purported to work, is extremely poor; essentially that there is no good evidence that chiropractic intervention is of any benefit to children for any illness. The full article is here: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2553791.

So what about the evidence for chiropractic helping kids with asthma? Searching the relevant medical literature (something real doctors do quite often) turns up only two well-designed studies that might help answer this question. One, a randomised controlled trial, examined the difference between “real” chiropractic treatment versus “sham” chiropractic treatment (to eliminate the placebo effect) in treating kids with asthma. There was no difference between the two groups. The second study looked at the use of chiropractic as an adjunct or “add-on” therapy for kids with mild to moderate asthma who were already receiving normal (that is, evidence based) medical treatment for their asthma. The conclusion? There was no additional benefit in adding chiropractic to standard medical therapy. These articles can be found here: http://www.ncbi.nlm.nih.gov/pubmed/7728627 and here:  http://www.ncbi.nlm.nih.gov/pubmed/9761802.

What about the wonderful benefits of chiropractic in treating or preventing recurrent ear infections? There exists one decent article in the medical literature relevant to this. Its authors were enthusiastic, and were studying, both together and independently, the effects of echinacea and of chiropractic manipulation on the risk and frequency of recurrence of otitis media in children. Echinacea actually showed a small tendency to make matters worse, and the chiropractic treatments had no significant effect at all. The article can be found here: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2573879.  The one reference cited in the BCA brochure as supporting the effectivness of chiropractic for treating otitis media is for an article which has not yet been published, and there is no indication as to what type of study it is, or if it is an experimental study at all; it could simply be an opinion piece for all we know. The fact that the principal author has some affiliation with Harvard University probably got them all excited about the prospect of respect by association.

I should take pains at this point to stipulate that all of the above is merely my opinion, for what it’s worth, as a traditionally trained western scientist and medical doctor. I point this out because, despite the fact that practically no-one will ever read this, the voicing of opinion is generally not permitted to be the subject of a libel action. Under British law, one is open to being sued for libel if one presents such statements as fact, rather than mere opinion. Interestingly, by the weird and wonderful convolutions of the legal system, though I may be on the far side of the world, anything published in the English language which can be expected to be read by anyone in the UK, and which can be construed to damage the reputation of a legal person in the UK (this includes corporations, bodies such as the BCA, and so on) can be the basis of a libel action before a British court. Certain jurisdictions have done the sensible thing in light of such madness, and passed their own specific laws negating this possibility (New York state is one example).

However, proving defamation generally requires that the allegedly damaging statement is, in fact, false. Thus, in support of Dr Singh, and rational people everywhere, I submit that the following statements are factual and true:

  • There is no credible evidence of reasonable scientific standard that chiropractic intervention is of any benefit whatsoever in the treatment of asthma in children.
  • There is no credible evidence of reasonable scientific standard that chiropractic intervention is of any benefit whatsoever in the treatment of recurrent otitis media in children.
  • Untreated children with asthma have a higher risk of adverse outcomes, including death, than do children with asthma who are treated appropriately with proven medical interventions.
  • Reliance upon chiropractic intervention, for which there is no evidence of benefit, in place of proven medical treatment for asthma in children therefore increases the risk of adverse outcomes in such children, including death.

If these facts upset people such as the BCA, that’s just too damn bad. You do not have the right to not be offended. If you feel these facts are not true, then the solution is very, very simple: provide the evidence which shows these assertions are false. It’s what you should have done in response to Simon Singh’s article, but you did not, because such evidence simply does not exist. Instead, you appeal to heavy-handed legal maneuvers in an effort to win a battle of attrition by making it both less irritating and less costly to simply give up, retract such statements, and walk away. Such tactics are cowardly, wasteful, and reflect a pitiable inability or unwillingness to admit that the tenets of your so-called profession have little if any basis in verifiable reality. It is unfortunate indeed that the current legal system allows such abuse of process and harrassment of those who, unlike you, strive to provide bona fide evidence-based information to a public all too susceptible to your quackery.

Posted by: Chris Cole | March 20, 2009

Why am I paying for idiots to support charlatans?

Along with a lot of other Australians, I have just received a not-unexpected letter from my private health insurance company (MBF in my case) advising me that my premiums are increasing by 7.69 % starting from April 1st (and sadly, I suspect it will not be a joke). Being a young, pretty healthy guy, I have very little need of private health insurance. Being a doctor, I have even less need of it; it’s perhaps not a widely known fact, but we medicos are a little incestuous and as a standard courtesy we don’t charge each other for medical services (this of course does not extend to charges from the hospital itself). The only circumstances where private health insurance would be useful to me is if I have elective surgery done in a private hospital (and need to pay the hospital’s fees, not the doctor’s), or if we decide to have a baby. If I am seriously injured or critically ill, I will be going to a public hospital as a public patient; the former ensures a higher overall level of care, and the latter ensures I won’t have a huge co-payment to make because private health insurance pays nowhere near enough, especially for complex or prolonged admissions to hospital. No, I’m afraid the main reason I maintain private health insurance is purely mercenary; the insurance premiums cost me less than the Medicare levy surcharge would add to my tax each year. Even if I never use it, it’s cheaper to pay MBF for hospital cover than it is to pay the tax penalty for not having health insurance.

C’est la vie. However… I also pay for extras cover, which partially pays for things like dentistry, optometry, physiotherapy, etc. And some of these services I do, in fact, need and use (e.g. going to the dentist). On perusal of the policy summary that arrived with my notice of a price hike, however, I note that MBF extras insurance also covers chiropractic, acupuncture, naturopathy, aromatherapy, Bowen therapy, Feldenkrais, herbalists, homeopathy, iridology, kinesiology, and reflexology, among others. MBF will happily pay up to $200 a year in benefits for these “therapies”. This is more than they will pay per year for optometry and eyeglasses or contact lenses. It is the same amount allowed per year for physiotherapy services. It is twice as much as they will pay for nicotine replacement treatment to help people quit smoking.

Why should I care? Because by virtue of MBF’s financially driven need to cater to the lowest common denominator of the gullible masses, I am paying for ignorant and/or irrational people to go to willfully dishonest and/or equally ignorant providers of these fraudulent “health services”. Along with everybody else who has extras cover with MBF (and most likely any other major health insurer in Australia), I am indirectly paying money to these charlatans, simply because a large chunk of the public is too poorly educated to recognise bullshit when they see it, and because to stay in business MBF need to attract as much of population as they can, including the idiots. This is much like the situation politicians find themselves in; in order to get elected, their statements and policies must cater for and appeal to the ignorant, biased and irrational amongst the population, as well as everyone else.

In a democracy, everybody’s voice has equal merit, and this is (for many reasons and despite certain drawbacks) rightly so. The advancement of the body of medical knowledge, however, proceeds by something called the scientific method. It is not a democratic process. It is a logical one. It is the process that has produced the technology that allows us to send space probes to other planets, to fly to another country, to power and provide water to our homes, to read this very article on the internet, and to understand the true causes of illness and disease, and provide treatments for them that actually work. Modern medicine does not advocate particular drugs, operations or other treatments because an ancient book says so, or because that’s the way they did it when grandpa was a lad. We use drugs and procedures that have been demonstrated, time and time again, to work. Many supporters of so-called complementary therapies seem to view science as some part of a conspiratorial establishment, suppressing the quest for knowledge that lies outside the mainstream. The irony is that nothing could be further from the truth. Scientific progress is made by seeking out the mysteries, the things we don’t understand, asking specific questions about those things, and testing our ideas about them, in order to provide answers to those questions and both broaden and deepen our understanding of the way the world works.

So, if someone comes up with the idea of say, homeopathy and asserts that it works, that’s fine. Cool. Bring it on! There is so much human suffering that we cannot treat very effectively, we are always on the lookout for new ways of helping people. The more the merrier. However, unfortunately for the many purveyors of snake oil out there, we do have one teensy weensy little stipulation. A condition that must be met, if you want the big bad medical establishment to take you seriously, and treat your ideas with any sort of respect. You have to actually prove that it works. This means providing actual, real, objective and independently verifiable evidence that it works. No, heart-warming anecdotes about one brave little boy’s miraculous improvement doesn’t count. Petitions from hundreds of people testifying that it’s the best thing that ever happened to them don’t count either. There are standards of scientific evidence. They’re pretty simple and very straightforward. Meeting them can be tricky, depending on the question you’re asking, and what you’re trying to demonstrate, but understanding the type of evidence required is not hard. We can, and do, teach it to primary school children.

Every single drug, operation or other intervention employed by medical professionals in Australia has met these requirements. It is simply illegal to sell a drug if it cannot be proven conclusively to do whatever it is the manufacturer claims it can do. Individual doctors may be biased for or against particular treatments, often with good reason though sometimes not, but as a whole, the medical profession will (and does) accept, incorporate and use any and all methods that are properly demonstrated to work.

There is no such thing as alternative or complementary medicine. There is simply medicine, and the rest which does not work.

I see no reason why I should continue to subsidise the scientific illiteracy of the masses and line the pockets of the liars and thieves who exploit them. Do you?

« Newer Posts - Older Posts »

Categories