blog.bioethics.net

AJOB Editor Glenn McGee To Be the New John B. Francis Chair in Bioethics
and AJOB to Move to Center for Practical Bioethics in Kansas City

Glenn McGee is moving to Kansas City to assume the John B. Francis Chair in Bioethics at the Center for Practical Bioethics. So, we are moving! The Center for Practical Bioethics is about to become home to the editorial office of The American Journal of Bioethics, bioethics' most cited, most read journal--that is if they can figure where to store all our glowing ice cubes, plastic puzzles, and AJOB pens (assured not to influence one's prescribing practices).

The press release about the Francis chair is below or can be read directly on the Center's website.

To hear Glenn's profound musings the challenge of his new role as chair, take a listen here.

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Glenn McGee named to John B. Francis Chair in Bioethics
Glenn McGee, PhD, becomes the second holder of the John B. Francis Chair in Bioethics on January 1, 2010. He follows John D. Lantos, MD. The chair was established in 2005 with a $3 million endowment from the Francis Family Foundation for the Center for Practical Bioethics in Kansas City.

The Francis Chair was designed for an individual with a national stature in bioethics, a proven track record in teaching and research and proven leadership qualities in fostering excellence in collaboration. Dr. McGee will engage in public outreach and consult with policymakers on medical ethics issues.

"Dr. McGee brings enormous expertise, experience and energy to his new role as the John B. Francis Chair in Bioethics," says Myra Christopher, president and CEO of the Center. "Dr. McGee is known for a pragmatic approach to bioethics, making him a perfect fit for the Center for Practical Bioethics.

"In my opinion, no other bioethics program is as effective at combining public engagement and scholarship," says Dr. McGee. "The Center for Practical Bioethics has a 25 year history as the peerless maverick in advancing the discussion - and resolution - of the ethical problems posed by biomedical science. I could not be happier or more honored to join the outstanding team at the Center as the John B. Francis Chair in Bioethics."

Dr. McGee's research ranges widely across ethical, legal, social and economic issues in biomedical science, and has resulted in more than $3 million in research funding and the publication of more than 100 articles, essays and reviews in peer-reviewed scientific, medical, and ethics journals, such as Science, Nature, JAMA, as well as oft-cited contributions to many encyclopedias, textbooks, law reviews, and other scholarly publications and books.

He has written two books, The Perfect Baby: Parenting in the New World of Cloning and Geneticsand Beyond Genetics: The User's Guide to DNA. He has edited three others, including The Human Cloning Debate (4 editions); Who Owns Life; and, Pragmatic Bioethics (2 editions). His most recent book is tentatively entitled Think Different: Autism and Bioethics.

In 2010, he is editing a new bioethics textbook for Wiley entitled Contemporary Debates in Bioethics, and is the bioethics editor for The Encyclopedia of Applied Ethics. He founded and served as Senior Editor for MIT Press Bioethics Books.

Dr. McGee is the founding Editor-in-Chief of the nation's leading journal in medical ethics, The American Journal of Bioethics, which will be based in the Center along with its subsidiary journals, AJOB Neuroscience and AJOB Primary Research and its 30 million visitor-per-year website, bioethics.net. He serves on more than a dozen editorial boards for peer-reviewed journals, as well as the ethics committees of the two organizations for scientific and medical journals.

Dr. McGee appears frequently in the news media, including "All Things Considered" on National Public Radio, PBS Frontline, The Today Show, Oprah, Anderson Cooper 360, Good Morning America, 60 Minutes, and 20/20. He has written bioethics columns for The Scientist, Hearst News Service; New York Times News Service, and MSNBC Online. He is on the cast of the PBS show Second Opinion, and a frequent guest on CNN Headline News, for whom he is a regular contributor.

Dr. McGee has given more than two dozen endowed and named lectures and has taught bioethics to incoming members of congress, chief justices of the state supreme courts, and for ten years at the University of Pennsylvania, where he created an undergraduate minor in bioethics.

Links:

Bio brief, Glenn McGee, PhD
Podcast, Introducing: the new John B. Francis Chair in Bioethics, The Bioethics Channel,11 minutes 39 seconds
About John Francis

John B. Francis and his wife, Mary Harris Francis, were well-known in Kansas City and nationally for their support of charitable causes.

During a 46 year career at Puritan Bennett, Mr. Francis developed life-sustaining respiratory technology. As a philanthropist, Mr. Francis provided tremendous support to advance pulmonary medicine through the Francis Family Foundation.

At the Center for Practical Bioethics, Mr. Francis served on the board of directors and provided significant financial support throughout much of the Center's history. The John B. Francis Chair in Bioethics at the Center for Practical Bioethics was established in 2005 by the Francis Family Foundation to honor the life of John B. Francis.

About The American Journal of Bioethics

The American Journal of Bioethics, better known as "AJOB," is a peer-reviewed journal with its editorial offices in the Center for Practical Bioethics. Only 10 years old, the Chronicle of Higher Education opined that "perhaps never in the history of publishing has a journal risen to the top of its ranks so quickly."

AJOB is produced in a novel format that is aimed not just at scholars but at all medical professionals, policymakers, scientists, and a sizeable number of patients and students. Each issue contains a complete treatment of several important issues in bioethics together with open peer commentaries by those from all relevant disciplines.

A NEW Presidential Commission on Bioethics.
We Christen Thee, Pucks-Bee. Let God Be Praised.

We all have a great deal to be thankful this Thanksgiving, and now we have one more thing to add to our list: another presidential bioethics commission. President Obama has made good on the implicit and then explicit promise to put bioethics not only into the White House but the Executive branch more generally. PCSBI. The Presidential Commission for the Study of Bioethical Issues. Known by any other name (or acronym), it's simply too much of a mouthful.

Apart from the Chair, Amy Gutmann, bioethicist and president of the University of Pennsylvania, and Vice Chair, James Wagner, Emory University's widely praised president, the membership of the commission remains a mystery, the sort of thing bioethicists like me wager about. Doubtless Robert George and William Hurlbut won't be on anyone's short list this time around, but they will have plenty to carp about in The New Atlantis.

Summer Johnson, PhD

Caplan: Pay Up for Quality Care, Or Else

The trent toward concierge medicine is not a good thing, says Art Caplan, today on MSNBC.com. Why not just draw a big bright yellow line across the street that indicates that "the haves" can get quality care over here and "the have nots" cannot get quality care over there? That's really what this system amounts to.

Oh and while were at it, why don't we just shout through a megaphone that the primary care system is broken and in lieu of fixing it, we'll just set up these private clinics so that those who demand to have good quality primary care can get it and leave the rest of those who are disenfranchised to just muddle through until we can find a political solution that both sides can agree upon--that is once we can stop bickering about whether the government will pay for abortions or not?

As for Arthur Caplan's views on the subject, you can read them below or click here to read his most recent MSNBC column.

Concierge' care is just another word for bribe
by Arthur Caplan

One sure sign that something is very broken in America's health care system is the rise of so-called "boutique" or "concierge" medical practices.

These are arrangements where doctors expect patients to pay extra premiums to see them, on top of what insurance pays. There already some 5,000 primary care physicians in the United States who've shifted to this model.

Why is this notion of first-class medicine for an extra fee a bad idea? There are two reasons. First, you shouldn't have to pay a bribe to get decent service from your doctor. And, second, the expansion of these fee-based practices means fewer doctors left for those who cannot pay the luxury rates.

Letters have gone out to tens of thousands of patients across the country in the past few years, solicitations from doctors shifting to concierge care.

It works like this: The family doctor, general practitioner or internist writes to say that if patients don't pony up a fee of $1,500, $2,000, or more, then they'll be dropped from the practice.

Of course, these letters don't openly threaten extortion. Instead, the offer to join a concierge or boutique practice comes in the form of an invitation for patients to pay more for something better. Patients are told they'll get better service for the extra fees, with bonuses like comprehensive physical exams, longer appointments with no waiting, prompt responses to phone calls, access to the doctor's cell phone number and help negotiating access to specialists if they're needed.

Patients may not be told that if they don't pay the fee, they'll likely be seen by a less-skilled staffer, usually a nurse practitioner, a physician assistant or a newer, perhaps younger, doctor.

Extra cash for extra care nothing new
Of course, boutique medicine is nothing new. We always have had first-class medicine in the United States. When you spend tens of thousands of dollars to get into the Betty Ford Center and other posh in-patient drug addiction programs, you are getting concierge care. And when CEOs fly to the Mayo or Cleveland Clinics to get their annual physicals, this is medicine for those with money to burn.

What is different about today's shift toward boutique medicine is that it is aimed at the middle-class. Ordinary physicians, overwhelmed with red tape, tired of arguing with insurance personnel, faced with backbreaking insurance and overhead costs basically are saying, "Enough!"

They want less work, less hassle and more money. So the message to patients is to dig deeper into their wallets to get the kind of decent, unhurried and attentive care they want.

The problem is, no one should have to pay more to get decent, unhurried and attentive care.

The whole system of primary care has broken down. Doctors are drowning in a sea of paperwork, insurance companies are siphoning off too much money, and managed care and lawyers are making the whole medical experience intolerable. All that, plus the highest prices in the world for drugs, tests and services combine to make it clear that concierge medicine is not a solution but only a symptom of a broken health care system.

Maybe boutique medicine wouldn't be so bad if what we were talking about was simply adding amenities -- plush robes, fresh coffee and WiFi in the waiting room -- to the standard care. But that is not what is happening.

Quality of care starting to shift
Concierge medicine is pulling already-scarce primary care doctors out of circulation. They are being replaced by physician-extenders at the same old prices. And the quality of care is starting to shift as the concierge crowd gets thorough exams while those back in medical steerage get a cursory look, if that.

The truth is, we all deserve the kind of attention from our doctors that our grandparents routinely expected and their doctors routinely supplied.

By turning medicine into just another commodity, it is only natural that the price will be jacked up for what used to be the standard of care.

Sadly, medicine is following the example being set by the overstressed American airline industry. They charge extra for the bottle of water, the breakfast roll, the right to take a bag on the plane -- and the businessmen pushing concierge medicine are following right in their quality-degrading footsteps.

Before we accept this airline model of medicine, perhaps it's time to think again about premium fees for basic services, and instead to get Congress to fix what is so obviously wrong with the nation's health care system: too much business and not enough care.

One Generation Burned Their Bras. Will Another Implants Theirs?

Victoria's Secret beware. There's a new game in town, says Fox News: the implantable, non-removable "Cup & Up" device. The bra that never sleeps--or comes off.

Rather than rehash all the staid arguments for and against breast augmentation, let's look at this procedure from a new perspective--a significant amount of resources could be saved replacing bras whose elastic bands become too worn out each year. From the male perspective, no more front or back clips to hassle with--there's nothing to remove at all!

But seriously, the idea that women could or worse yet should do away with some fabric and replace it with a breast implant is taking things a bit too far for my taste. Whatever happened to "chicken cutlets" or tissue paper? Moreover, who wants to, as these devices require, have a silicone implant on the inside and a set of straps connecting the implant over their shoulders? That must be one heck of an "up" to be worth such a hassle!

Given the improvements in "bra technology out there", I can hardly imagine that these implants are worth the medical risks inherent in surgically implanting silicone into a woman's breast at any age. As a proof of concept, great--we've now learned you can put half of a Wonderbra inside a woman and make it permanent. But for for most women's money, I'm guessing they'll stick with the actual bra and keep thumbing shopping at Victoria's Secret.

Summer Johnson, PhD

Caplan: New Mammogram Recommendations Accurate, but Not Right

While the data may support pushing back the timeline for routine mammograms from age 40 to 50 for women, Arthur Caplan questions the decision in his most recent MSNBC column saying that "there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women." More importantly, they probably shouldn't.

To read the entirety of Caplan's column, read below or click the link above.

Summer Johnson, PhD

Mammogram advice accurate but not 'right'
by Arthur Caplan, PhD

Did you hear an enormous thud around 3 p.m. yesterday? That was the sound of Secretary of Health and Human Services Kathleen Sebelius throwing her scientists under a bus.

Earlier this week, the U.S. Preventive Services Task Force, the government's major medical advisory panel, announced that they could no longer support routine mammographies for women under the age of 50 who were not in a high risk group for breast cancer.

They said that the number of cancer cases detected from such screening was too low, and that too many biopsies and further tests were being done in women who had hard-to-interpret test results but who turned out not to have the disease.

This new recommendation unleashed a tsunami of criticism from many breast cancer doctors, patient advocacy groups and women. In an msnbc.com poll, more than 80 percent of women said they were going to ignore the advice.

Emotional, snide -- and even paranoid -- accusations plagued the recommendation to end routine mammograms for women under 50. Some wondered why there were no true breast cancer experts on the panel. Still others suggested that the whole report was written with an eye toward the billions of dollars being spent on screening every year. And a few even wondered that if this was about men's health, rather than women's, would these scientists have been so quick to yank the plug on a screening test?

Critics of health reform sneered that this is what Obama has in mind for all of us if the government gets its cheap hands on health care -- cutbacks in crucial medical benefits now enjoyed by those with private insurance.

By Wednesday, Sebelius cried uncle, bulldozed over the task force and told women under 50 to forget the new advice, keep doing what they had been doing and talk with their doctors about screening.

So how did the poor scientists of the U.S. Preventive Services Task Force go from being the "gold standard" for deciding what works in medical screening (this is according to the Web site of Sebelius' own agency!) on Monday, to a bunch of irrelevant nerds by Wednesday?

That's because data and evidence have not, do not and never will be the sole determinants of health coverage.

Data-driven health care
The mission of this task force is is to evaluate the benefits of preventive services based only on data in the peer-reviewed literature and input from experts at other federal agencies like the Centers for Disease Control and Prevention, the National Institutes of Health, Veterans Affairs and other professional medical groups.

They are instructed to make their recommendations about the value of screening tests, such as mammograms, with little attention to the economic cost to society.

The critics were right about one thing: It is true that the committee recommendations are the sort of thing the Obama administration has in mind as part of health reform. But not as a way to ration care for the insured. The administration has been talking endlessly about using better data to figure out what works and what to pay for.

In this case, the task force found that screening all women in their 40s led to too many false positives and too much unnecessary follow-up testing for the number of lives it saved. They did not say that no lives were being saved. They said not as many as everyone thought. And not enough to justify asking every woman under 50 to get a mammogram every year.

Well, women fear breast cancer. So do their husbands, brothers, sons and fathers. There is no way testing for an especially dread disease that is at least somewhat effective is going to be cut back without screaming protests.

What's accurate vs. what's right
The data does not tell us what to do in setting a standard for testing or paying for it -- ever. We have to base these kinds of decisions on both data and values. How much do we fear getting a disease? How much are women willing to go through to avoid getting it? How much do we value saving younger lives and those of mothers of young children? These are as much ethics and policy question as they are issues of the facts.

Equally important, once a practice is firmly in place, such as screening for breast cancer, it is very hard to change beliefs and deeply held convictions overnight. If you tell women to get tested early and often for the better part of two decades, if you tout early detection as one of the triumphs of the "war on cancer" and if you stick breast self-examination cards into every shower stall in America then one day say, er, nevermind, forget it -- don't expect that to go down very well.

Screening is what responsible and health-conscious women do to take control of their bodies and prevent disease. Those are commendable and powerful virtues, and -- it seems --more compelling than a pile of bland data.

Doing the right thing and taking the time to protect yourself against breast cancer has moral weight that policy makers, as Secretary Sebelius found out, ignore at their peril.

There is no reason to doubt the accuracy of the scientists' finding that evidence does not support routine mammography for most women under 50. But there is every reason to doubt that the numbers they compiled will be sufficient to overturn a medical practice that carries so much ethical weight for women.

Give Me ObamaCare and Give Me Your So-Called "Death Panels." It's Surely Better Than What We Have Now.

The conservative blog, mercatornet.com, invited yours truly to be part of a debate on health reform, the controversy over so called "death panels", and my views on the future of the American health care system.

The piece written in opposition to mine can be read here, but I can summarize it quite quickly: Ms. Valko support Sarah Palin's view that "death panels" are on their way or may already be here and that we have much to fear from the BIG, BAD GOVERNMENT and that anyone who has a disability or who is less than perfect will be cast aside in the Obama regime.

Hogwash.

My column is also posted in full-text below or can be read by clicking here. You can read my views below, so there's no need to summarize them here. But if you can't intuit them from the title, I'd be surprised.

Summer Johnson, PhD

Give me ObamaCare and my grandmom is doomed?

What is the system now?

The current United States healthcare system can be summarized in a few words: under-performing, over-priced, and inequitable. Unlike the UK or Canada, the US has for a large employer-based healthcare system, which means that many -- children and adults -- receive healthcare benefits via their employer. The remainder receives benefits from three other government sponsored programs: Medicaid (for those of a socioeconomic status too low to be able to afford to pay for health insurance and do not qualify for employer-based insurance) and Medicare (for those over the age of 65) and the Veterans Administration system. There are a few other categories of individuals who qualify for these government programs including the chronically disabled, etc, but this is it in a nutshell.

So if I had to add a fourth word to describe the United States healthcare system I would use: potpourri; and I don't mean the good smelling kind. I mean a mish-mash of systems and providers. Worst of all, when the United States has an unemployment rate of 9.5 percent as of October 2009, this adds another nearly 10 percent of people who cannot receive insurance via their employer. This is where an employer-based system of providing healthcare coverage breaks down.

There must be another way. Millions of Americans are using COBRA (short-term gap coverage for recently terminated employees offered by employers) now subsidized by the government now under ARRA, plus Medicare, plus Medicaid. Thus, the public option so hated by critics of reform is doing quite well, thank you, IS effectively providing health insurance for a HUGE proportion of the nation. Failing to extend insurance options to the rest of the American 45.7 million Americans is a true moral failing.

What will the new system probably look like?

The "new system", most commonly known as the "public option", scares many people because critics have obscured the fact that most Americans use government sponsored healthcare -- including everyone in Congress.

However, in fact the current proposal passed by the House of Representatives this past Sunday simply adds one more option to what everyone has. There will still be private insurers; patients will still be able to choose whatever doctors they want. Choice will still be a huge part of the "new system."

"So what has changed?" one might ask. The federal government is guaranteeing that there will be a federally run insurance program that will be available to all Americans, the same insurance program that Senators and Congressmen use, and it will allow an additional 90 percent or more of uninsured Americans to have access to health insurance. This program is most likely to be utilized by the young who cannot afford insurance premiums in the earliest years of their careers and the working poor who cannot afford premiums or who are not offered insurance in their jobs. The program will compete directly with private insurers, hopefully driving prices down, and creating greater competition in the healthcare market -- something all free market capitalists love! This could result in a reduction of premiums by 25 percent within the next 5 years. Yet private insurance plans will still exist and will still be available just as they always have been -- so the employer-based insurance system we know and some love will persevere.

This system would allow for public provision of health insurance options with the provision of care from any provider patients choose. This kind of system would put us in very good company. Canada, Western Europe, Japan, Australia, New Zealand and Taiwan all do it -- and with far better health outcomes and far less healthcare spending.

Is the fear over Obamacare "death panels" exaggerated?

Absolutely.

I mean, come on, "death panels"? When I first heard this expression, I assumed that the Grim Reaper would be one of the committee members.

Then I read the ridiculous stories about how Ezekiel Emanuel wanted to kill my grandmother, I laughed out loud. Anyone who ever has even met Zeke knows that he's an oncologist by medical training and would prefer that people NOT die of cancer, for one, or anything else for that matter.

Second, his argument -- --which is actually quite sound -- simply says that we have to allocate effort to different cases according to those who will receive the most benefit from the care we give them. This is the nature of rationing, which all healthcare systems have. So tough choices have to be made in situations when there are scarce resources. But on these panels, no one is going to make decisions about individuals. No one is going to say, "Washington is calling. It's time to turn off Grandmother's ventilator. She's costing the public health insurance plan too much money."

Americans have to trust someone to make the big decisions. For more than 40 years they have trusted private insurance companies, whether they have been aware of it or not, to make the decisions about whether Aunt Sue gets that angioplasty or that new drug. It really isn't the doctor. Doctors recommend; insurers approve. Anyone who has ever received a denial letter from an insurance company knows that.

So the question is whether Americans are willing to trust the United States government to set the healthcare budget and provide a third way to have access to healthcare for all, reduce overall healthcare spending, and hopefully over the long term improve healthcare outcomes.

I can't see how we can do worse than we are doing now. I really can't.

Can you trust members of the ethics committee to treat patients with dignity?

Healthcare professionals treat patients with dignity, not government panels. They take their needs and interests into account. But it is doctors who provide the care, not health policy advisors.

In the context of health reform, it is the job of policy analysts and health advisors to ensure that the system will provide the well, the sick and the dying with adequate care.

Much ado has been made of President Obama's "Independent Medicare Advisory Panels", but I would happily put Harvard's Atul Gawande MD and the National Institutes of Health's Ezekiel Emanuel MD, PhD in a room with former Governor and vice-presidential candidate Sarah Palin and let them duke it out over health reform any day and let the chips fall where they may. They have two MDs and one PhD on their side; she has rhetoric and a moose gun.

Yet, Palin tries -- and fails. She has supported reimbursement for time spent counseling for living wills and advanced directives (even though the latter do not work); it's the prior conversations between loved ones and the dying that matter, not the piece of paper

Yet Palin's attacks upon the (imaginary) pro-euthanasia bioethicists are clear. When talking about "Obamacare", she has described it as a "system [that] is downright evil". She refuses to accept a healthcare system where her parents or her child would have to stand "in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society' whether they are worthy of healthcare".

Yet I wonder what Ms Palin (and others who support her view) find more morally reprehensible: leaving 47 million Americans without any access to health insurance AT ALL or creating a government panel that would make decisions about how much care would be given to which Americans, all of them having had access to health insurance over their life span.

And yes, Ms Palin, that might mean that your aging parents might not get that third bypass surgery or that state-of-the-art hip replacement over providing well care for all children. Or is it "downright evil" in your view to leave the most productive members of our society -- the chronically underinsured or uninsured Americans aged 18 to 34 -- without access to affordable healthcare coverage? I wonder, is she or anyone else okay with leaving young women to die because they are unmarried and uninsured?

Generally, though, I am more sanguine than most about the ability of ethics committees or commissions to make good decisions about what should be done in terms of making policy. I think what patients don't realize is that most decisions about what kinds of care and what procedures are covered and in what amounts, about what percentages of procedures are paid versus unpaid, and about the reasons for all this, are actually done by committees. But in the current system, it's all done behind closed doors inside meetings of actuarial scientists and executives at pharmaceutical benefits companies and insurance companies.

So let me ask you this.

Would you rather have your healthcare decisions made out in the open as part of public debate by a public committee comprised of ethicists, public members, politicians, health policy analysts and others who specialize in making these kinds of decisions on a large scale to save taxpayers money -- or by the (much more) self-interested persons who work for the companies who have a bottom-line to make for their pharmaceutical benefit management company, insurance company and its shareholders?

For my money (and my health), I'd opt for the public panel any day.

**Thanks to Myra Christopher and Arthur Caplan for comments on previous drafts of this post.

Caplan: Swine Flu Response Isn't Even Worth Sneezing At

For all the planning, prioritizing, and head scratching done by state and federal governments for the coming H1N1 flu crisis this fall, we still have fallen short, says Arthur Caplan in his most recent MSNBC column.

Why? The reasons are plentiful, but if you ask me the answer is simple: a public health infrastructure so weak that I've seen spider webs that provide more protection against passing threats.

Caplan blames whining healthcare workers, too little vaccine and a number of other causes, but I'll let you read the essay yourself below or by clicking the link here. But no matter who's analysis you believe, it's clear---the swine flu response is pretty darn poor and shows no signs of getting better, and its our children and their caregivers who are paying the price--with their health.

Summer Johnson, PhD

U.S. swine flu response dismal at best
by Arthur Caplan

Few seem to want to say so, but this nation has mounted a dismal response to the swine flu epidemic.

By dismal I mean this: There's not nearly enough swine vaccine to go around, there are conflicted messages about when the doses and antiviral supplies will arrive and half of all Americans are reporting they are too afraid to get the vaccine even if they are able to find it.

Health care workers are throwing fits when directed to take the vaccine, even if they work around high-risk patients, and there's a breakdown of a strict distribution system to make sure the vaccine we do have is used to protect and save the most lives.

We have had the better part of a year to get ready for swine flu. And yet, the response to the pandemic H1N1 outbreak has been lousy. What would happen if a hostile power launched a large-scale bioterrorism attack against us with no warning?

The Obama administration bears much of the blame for the fear the public and health care workers have of the swine flu vaccine. The facts do not square with the fear.

Numbers of sick and dead are mounting
At least 129 have died in the United State from swine flu. Eighteen children died last week. Public health officials estimate that at least 1,000 adults have died so far from swine flu in this country alone. Hundreds have faced life-threatening hospitalizations. Millions more have been terribly sickened and lost time from work.

The fear factor is simply confusing. To put it bluntly, it makes no sense to be more afraid of the swine flu vaccine than the actual H1N1 flu. No vaccine in the past two decades has killed nearly so many children and adults. Yet, somehow the administration, public health officials and organized medicine and nursing have lost the battle to overcome fear, ignorance and just plain kookiness when it comes to the importance of vaccination for those at greatest risk.

Worse, efforts to tell health care workers -- health care workers! -- that they must get vaccinated if there is vaccine to give them have faltered. Nursing unions are in court arguing that they should have a right to choose when it comes to vaccination.

Few leaders in medicine or public health -- much less the White House -- have spoken up and said that if you are a health care worker, your ethical promise to put the health and safety of your patients first means you have an absolute duty to get vaccinated against both seasonal flu and swine flu unless you have a serious medical reason not to.

Some media outlets and blogs are not helping, either. There are way too many stories about screwball theories insisting that the pharmaceutical industry is pushing vaccination on innocent children for profit, alongside equally nutty and nonsensical recommendations to use garlic, echinacea, astragalus and "immune system" vitamins to fend off a virus that can kill pregnant women and babies.

The idea that garlic is effective against both vampires and viruses would be funny if it were not for the fact that people are dying. Should we face a more serious biological threat, many more people who are happily putting rubbing alcohol up their noses, not getting their kids vaccinated and swilling Chinese teas will die.

One very clear lesson from the current swine flu epidemic is that our safety and security demand much more in terms of effective public education and communication then we have seen to date.

Flunking the swine flu test
When it comes to the effective distribution of the swine flu vaccines and drug supplies we do have, America is flunking the test. Every day I listen to hospital officials complain that they cannot get enough vaccine, or even ANY vaccines, to take care of their high-risk patients and their staffs.

Yet, some swine flu vaccine, according to recent press accounts, has been released to more than a dozen companies including Wall Street firms Goldman Sachs, Citigroup and JP Morgan Chase. Some professional sports teams have gotten vaccine and vaccinated their players and coaches.

When politicians have bothered to get involved in talking about swine flu and what to do about it many have spent that time sounding like fools. Perhaps the best example has been the rhetoric directed at the idea that prisoners, including those at Guantanamo Bay, ought not to get vaccinated.

The posturing before the cameras in a competition to offer the worst advice has been a rare example of bipartisanship. Sen. Joe Lieberman, I-Conn., Rep. Bart Stupak, D-Mich., and the ever mind-numbingly off-base Rep. Roy Blunt, R-Mo., screamed that "accused terrorists will be first in line for H1N1 vaccines." At least Blunt remembered that they are only accused.

The point, however, is that even if you don't give two hoots for those stuck in limbo at Guantanamo or locked up in prisons and jails all over the nation, these prisoners pose a huge threat to you.

Prisons are prime breeding grounds for disease, including swine flu. The prisoners infect the guards who bring the virus home to their pregnant wives and kids. From there, it moves out into the neighborhood, the school, the airport and beyond.

Examine response for future crises
I am sure the crowd imprisoned at Gitmo will be happy to do their best to infect our troops. If you want to control the spread of swine flu, the best move is to vaccinate prisoners -- whether they want to be vaccinated or not.

We are not doing a good job with swine flu. We need a national commission to review what has gone wrong with the response to the pandemic. And that same commission needs to take a long hard look at the lessons we need to learn before the truly nasty bug or batty terrorist packing anthrax, botulism or tularemia shows up on our shores.

The November Issue of AJOB Is Now Online!

With H1N1 and flu vaccines on everyone's minds, the November issue of The American Journal of Bioethics couldn't be more timely. What do people think about the measures necessary to protect ourselves from flu? Do we, or more importantly should we trust our government to protect us in a pandemic?

Baum et al ask these questions and more and conclude that in a flu pandemic the public is likely to resist precisely those public health measures that work--like social distancing--because they are impractical and to be distrustful of our government.

Also in this issue is Zivotofsky and Jotkowitz's response to Dignitas Personae, or "A Jewish Response to the Vatican's New Bioethical Guidelines", as they call it. Open Peer Commentators from all faiths, as well as secular authors, respond.

In this issue's third target article, Burris and Davis consider the question of whether researchers have a responsibility to assess social risks of research prior to conducting it. Respondents to this Target Article come down on both sides: some concluding this is too burdensome for researchers, others concluding this is the work of an IRB and does not require additional empirical research, others arguing for precisely this kind of empirical data (more data, more data, more data).

So whether you are interested in pandemic flu, research ethics, or stem cells and religion--this issue of AJOB has something for you. Check it out today, and all month, on bioethics.net.

Summer Johnson, PhD

Q & A on What is a Blockbuster Anti-Wrinkle Cream Worth, Morally Speaking
Or How Many Fetuses Does It Take To Make a Great Cosmeceutical

Question: What is it worth to produce a blockbuster anti-wrinkle cream?
Hypothetical Answer from Cosmeceutical Company: A single skin biopsy of a 14-week old voluntarily aborted fetus from a minor with consent from her parents.

Question: What is it worth to produce a blockbuster anti-wrinkle cream?
Hypothetical Answer from Any Pro-Life Advocacy Group: We see aging as a natural part of the human life span, but if companies want to do this research it is absolutely fine to use morally acceptable alternatives to embryo and fetus research such as animal research or collagen, as you promote human dignity.

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Walking through the cosmetics aisle at your local pharmacy or department store, you might not be able to distinguish Neocutis from any other of the high priced facial creams that promise women (and men) a younger, fresher, wrinkle-free face. Nearly every facial cream, cleanser, and mask is chocked-full of the sorts of exhilarating and yet seemingly possible promises that make us want to run out and buy a tube of the latest and greatest face flattening, plumping or softening cream makes us feel hopeful that immortality or at least (superficial) youth is just one swipe of the charge card away.

One more addition to this increasingly crowded market of products is Neocutis, a Swiss product made of PSP (processed skin proteins) which promises to treat everything from eczema to psoriasis to severe wounds to wrinkles and more.

But here's the catch: these "processed skin proteins" are derived from the cell lines of a single set of skin cells from a 14-week old aborted male fetus in Switzerland.

They were harvested as a result of an abortion from a young girl whose parents, according to the Neocutis website, gave consent for to the abortion and to donate the body of the fetus to medical research. Thus the Lausanne, Switzerland company took those cells and made the proteins into what by many accounts to be a wonder-cream for repairing damaged skin.

Whether the abortion was elective or medically required remains under debate whether one believes the pro-life version from the World Net Daily crowd or the Neocutis website on responsible use of fetal skin cells. My guess is that the truth is somewhere in between.

Regardless of the reasons why the abortion took place (the facts are unclear), one can only hope the young girl and her family were not induced to undergo the abortion for financial reasons. Setting that aside, the more compelling ethical question remains: what moral complicity exists for those who choose to put fetal skin protein creams on their faces? Do the purchasers of Neocutis in fact endorse the use of fetal tissue for medical research generally or specifically for cosmetic research?

Of course, they do. Beyond that, the cautionary tale here is that absent clear labeling that says "This product contains embryonic, fetal or other kinds of tissue, cells, or their derivatives" our cosmetic aisles are about to very quickly to become filled with thousands of products that contain precisely the biological materials that consumers would have no idea they are smearing on their faces.

Yet for some, this will have no moral implication at all. For them, fetal proteins in a face cream aren't any different from animal or plant protein because for them the moral status of the aborted fetus doesn't have the moral status to give one concern if consent to both abortion and research took place.

But for many, it would be unthinkable to fetal ANYTHING into their deepening wrinkles to make them become less so. In fact, many would rather have crow's feet deeper than the Grand Canyon than have a fetal tissue cell touch their face as a result of their moral conviction. And for them, more power to them.

However, for those women who voluntarily elect for whatever reason do donate their aborted fetuses to science, we certainly ought not to discourage them. It can for many turn a gut-wrenching decision into something that makes them feel they have given something back to society. However, dialogue is necessary as to what sorts of uses those precious resources ought best to be used.

$100 or more tubes of face cream are a rather low priority compared to the hundreds to thousands of other research priorities that still exist for these cells and tissues. Personally, I neither believe in their entirety Neocutis' press materials or the pro-life website's versions of the story surrounding this woman's gift. Absent those facts, I think all we can really ask ourselves is "Do we really want to "vote with our wallets" and purchase products with contents procured by morally questionable means? With the verdict still out, my wallet will be voting no.

Summer Johnson, PhD