Organ Donation: To Opt In or Opt Out, That is the Question

Organ shortage is a serious problem in the United States. About 20,000 organ transplants occur every year in the U.S., and 116,689 Americans are currently on a waiting list for an organ, with kidneys being the most needed organs. Furthermore, the obesity epidemic is also contributing to the shortage; a quarter of prospective donors are too obese to donate their kidneys. People typically wait 3-5 years for an organ, and thousands die every year (an average of 18 people per day) because they do not get the organs they need. Research is being done using embryonic stem cells and engineered scaffolds to try to regrow organs, but the complexity of these organs and the number of different cells and tissues comprising each organ tell me that this is not a possibility in the near future. However, there is something that can be done right now. Here I will present my case for the U.S. switching from our current opt-in program (i.e. the default is non-donor, and you must physically give consent for your organs to be donated when you die) to opt-out or presumed consent (i.e. the default is donor, and you must request to be taken off the list if this is what you want).

One of the major problems with organ donation is that people don’t want to acknowledge their mortality. It’s difficult to think about what will happen when you are dead, and it may seem weird for someone to take your organs. Other people are indifferent, apathetic, or don't want to take the time to opt-in when they get their license.

Consider Germany and Austria, which are very similar countries. Germany has an opt-in system and a 12% donor rate, while Austria has an opt-out system and a 99% donor rate! Here’s another comparison: Spain, with an opt-out system, currently leads the world with 34.4 deceased donors per million people, while the U.S., with an opt-in system, has 21.9. Clearly the default matters in this situation. The government is taking a stance and telling people what it recommends, and this greatly affects how people respond. In opt-out programs where the default is being an organ donor, there are higher donor rates.

Illinois has an interesting system called “mandated choice,” in which people are required indicate their preference. As a result, they have a 60% donor rate compared with the national rate of 38%. This program is a step in the right direction, as it at least solves the problem of people being indifferent or not taking the time to consider organ donation.

One of the major criticisms of the opt-out program is that freedom and liberty are being compromised. However, this is not the case because you still give each person the opportunity to opt out, and it is ultimately his or her responsibility to make this choice. Another potential problem is that an opt-out program may not actually increase organ donation rates, as Johns Hopkins researchers suggest. They say that physicians always approach the family members of the deceased and ask whether they would still like to donate their loved one’s organs. The family gets to make the final decision, regardless of the deceased’s intentions. I can see where they are coming from because you want to be respectful of the grieving family. However, people don’t always think the most clearly when they are emotional and grieving. Further, this limits the autonomy of the deceased, as they may have wished to have their organs donated. If this were followed more strictly, perhaps we would have more organs donated, especially if we switched to an opt-out program.

Adopting an opt-out program in the U.S. would definitely increase the donor rate, which is a step in the right direction. More stringent enforcement of people’s wishes by doctors would enable this to be carried out, decrease the organ shortage, and save thousands of lives.

Gun Control

As a student at a school of medicine and public health, I felt compelled to write about gun control, especially in light of recent events. The lack of strict gun control in the United States is a public health crisis.

In a recent Time article, Fareed Zakaria eloquently argued for gun control. He reports that the gun homicide rate per capita in the United States is 30 times higher than in Britain and Australia, 10 times higher than in India, and four times higher than in Switzerland! Why is this? Is it possible that the United States has more people that are psychologically debilitated? This seems unlikely. The answer appears to be the number of guns. In the United States there are 88.8 firearms per 100 people compared to 54.8 in Yemen, 45.7 in Switzerland, 45.3 in Finland, and all other countries have fewer than 40. Zakaria also reports that crime in America has significantly decreased in the past few decades with the exception of one category of crime: firearm homicides, whose rate has not changed in the past few decades.

Critics claim that gun control is unconstitutional, namely because it violates the 2^nd Amendment’s right to bear firearms. To that, I urge you to consider the initial motivation behind the 2^nd Amendment and the ruling by the Supreme Court in United States v. Miller. The actual text of the 2^nd Amendment is as follows: “A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed.” Note the word “militia,” which the Supreme Court explained to mean a group of people enrolled for military discipline, and that when they were called for service they would appear bearing arms supplied by themselves. Therefore, the 2^nd Amendment refers to bearing arms in the military intended for the protection of the country, not bearing arms for private purposes. The Supreme Court seriously overstepped when they declared in District of Columbia v. Heller that the 2^nd Amendment protects an individual’s right to bear a gun.

Critics also claim that gun control will not decrease gun violence or even violence in general. People will still be able to obtain guns on the black market. Also, there will still be just as much crime, but the only difference is that people will use weapons other than guns. However, this argument is not cogent. Having a gun in the home allows you to act on impulse and to complete an act that you might not have otherwise done. An article in the Journal of Epidemiology reported that people with guns in the home were at a greater risk than those without guns of dying from a homicide in the home. Furthermore, according to an article in the American Journal of Psychiatry, most people who commit suicide are ambivalent about doing so. Having a gun makes it so much easier for people to commit suicide if they are ambivalent.

For the health and safety of our country, our leaders would be wise to enact stricter gun control laws. The risks gun control are very minimal, or perhaps nonexistent, because doing so will only decrease gun violence. The only downside of gun control is that our freedom is slightly limited, to which I respond by saying that sometimes we have to make sacrifices for the greater good.

Reflections on My First Day of Medical School

Today was the first day of what I hope will be a very exciting and rewarding medical career. My very first instructors were patients, which I think is really incredible. It made me realize that much of my medical education will come from the patients I see. A group of about 10 patients with diseases such as ovarian cancer, Alzheimer’s, and heart disease came to speak with us. One by one, these patients walked to the front of the lecture hall and told us about their diseases. The whole setting was very dramatic. Then we broke up into smaller groups and got to ask the patients more personal questions.

The first patient I got to talk with had battled depression most of her life. Today she taught me that we should not be afraid to talk to people with mental illness about their condition. There is quite a stigma associated with mental illness, and we often feel like it is inappropriate for us to discuss this with the affected individual. Additionally, sometimes we do not know how to handle it or what to say. Asking the individual about their illness shows that you care. Furthermore, she spoke very highly of her psychiatrist and said that the psychiatrist had confidence in her. I will try to remember to always have confidence in my patients and their ability to improve.

The second patient I talked with had contracted Polio at a young age and had been in a wheelchair nearly her whole life. Today she taught me that we should never shy away from trying to include people with disabilities. Oftentimes we will not invite disabled people to events, gatherings, or parties because we feel that the disabled people might not fit in. It is bad enough that these people have disabilities, and not inviting them only makes it worse. We should always extend the invitation and allow the disabled person to decide whether or not he/she will attend.

Right from day one, I feel I have learned how to be a better doctor, and this knowledge did not come from my professors, but from patients. It was definitely a day I will remember for the rest of my life.

It's Time to Take Resposibility for Our Health

If you smoke or drink, that’s no longer your fault, it’s your genetics. You just inherited a predisposition for addiction. If you are obese, that’s no longer your fault, it’s a glandular problem, a metabolic disorder, or due to your genetically-caused diabetes. We have been pathologizing all of these problems that our society faces. The bottom line is that people need to take more responsibility for their health.

By pathologizing all these problems, people feel like these issues are not their fault. This can lead to a sense of helplessness, and people feel like they cannot do anything about these problems, and so they do not do anything about these problems. This functions as a positive feedback loop and only makes the problem worse. Also, they think that their only solution is medicine or surgery, which can have a lot of deleterious side effects and complications.

At the same time, I don’t want to generalize; there are situations where this doesn’t apply. Some people with diabetes are extremely overweight or underweight, and there is not much they can do to remedy this. Charles Fried, in Right and Wrong, goes so far as to say that “when the disadvantage is medical or educational it is a disadvantage to the person rather than to something which the person has done or chosen” (126). Essentially Fried argues here that a person’s medical problems are not that person’s fault. This seems to imply that most medical problems are genetic rather than environmental (i.e. caused by diet, lifestyle, etc.). He says that medical misfortune is misfortune to a person just like a fire can be misfortune to a house. In some cases this argument might be valid, but most of the time this is not the case. If this were how society viewed medical problems, then this would be a moral hazard. If people were not held responsible for their medical problems, then there would be less incentive for them to take care of their bodies because they feel that their medical problems are not their fault and that there is nothing they can do about them. From a scientific perspective, there are certainly some diseases that are genetic and are not the person’s fault; that’s just the card they were dealt. However, most diseases have at least some environmental component, so a person should take responsibility for their illness. Failure to do so will only worsen the obesity epidemic in the United States, which leads to heart disease and other cardiovascular problems, diabetes, and cancer. This, in turn, puts a strain on the health care system and causes us to spend even more money on health care. Therefore, by taking responsibility for our health, our citizens will not only be happier and healthier, but we will also partially remedy our health care spending crisis.

Affordable Care Act

I initially thought the Patient Protection and Affordable Care Act (PPACA, or just ACA; watch this video from the Kaiser Foundation for a great overview of the law) was going to be ruled unconstitutional by the Supreme Court. It doesn’t seem constitutional to force everyone to get health care, and this is exactly what Chief Justice John Roberts said. We don’t force everyone to eat healthy. We don’t force everyone to exercise. However, Roberts argued that the mandate is actually a tax levied by Congress on a citizen’s decision to forgo insurance. This logic seems to follow, as we tax other decisions that people make, such as smoking. Also, our government taxes people to pay for health care for people over 65 (Medicare), so why would it not be allowed to do the same for those under 65? Regardless, I am thrilled that the ACA will be carried out. Everyone should have access to health care. Health care should be treated as a basic right; this is the way it is viewed in most other Western countries. Indeed, one of the reasons I have chosen to become a doctor is to provide health care for as many people as I can.

As an aside, I have a newfound respect for Chief Justice Roberts. He was not afraid to rule against his fellow conservative colleagues. I’ve always had a lot of respect for Justice Anthony Kennedy, typically known as the “swing vote” because he sometimes sides with the conservative justices and other times with his liberal colleagues. He doesn’t let politics get in the way of his decision-making, and this time I am glad that Roberts did the same. I commend him for the courage it took to make this decision.

So what does this mean for us as medical students and future health care providers? My first thought is that we are going to be busier and have more patients to see. On the plus side, we won’t be dealing with the issue of having to provide care for the uninsured, and I would imagine it is currently very hard for doctors to prevent giving care to patients that lack insurance. Therefore, the ACA will decrease the burden of uncompensated care on doctors and hospitals. In addition, there should be less insurance company bureaucracy to deal with, so we will have more time to care for our patients. Lastly, the ACA will give states and local governments more resources for preventative care, which will help our population become healthier. After all, this will be our goal as doctors.

My only real concern is the cost. The Congressional Budget Office estimates that the ACA measures will cost us $938 billion over 10 years. However, the ACA also includes provisions for cost reduction (mostly from health care providers and insurers, which will be paid less, mostly in the Medicare department), and the country will actually be saving money. This seems amazing, and I am curious to see if this will actually happen.

Lastly, what does this Supreme Court ruling mean for our country’s imminent presidential election? I personally don’t think it will have too much of an effect because the bigger issue for the election will be the economy. However, according to a June Ipsos poll, 73% of independent voters oppose the ACA, which favors Romney, who has said he would work to repeal the ACA on his first day as President. This is rather interesting when you consider the Massachusetts health care law enacted during Romney's tenure as governor, which mandated that nearly every Massachusetts resident obtain health insurance. The smart move might have been to accept the ruling on the ACA and focus on other issues, like the economy. It will definitely be an interesting presidential election, but for now, it looks like many more millions of Americans will gain health insurance. This is definitely a reason to be happy.

A Whole New Breed

The students being admitted to medical school has changed drastically in the recent couple of decades. Medical schools are no longer just picking the students with the best MCAT scores and the best grades. While these are still two of the most important factors, medical schools are trying harder to find students that are well-rounded. As a result, the coming years will witness the birth of a whole new breed of doctors. The question I will try to answer is what does this change means for the practice of medicine.

One major change seen in students admitted to medical schools is their course of study or undergraduate major. Science majors have always dominated, and they continue to make up the majority. The percentage of applicants who are science majors has remained steady, but what’s changing is who gets in. Medical schools are now accepting an increasing percentage of non-science majors. For example, the University of Pennsylvania now matriculates a class with about 40 percent non-science majors. In 1999, a national survey of first-year medical students found that 58 percent took a social-science class for personal interest. In the 2006 entering class, the number was more than 70 percent. Additionally, humanities students also score better on the MCAT. Data from 2006 shows that humanities majors outscored biology majors in all categories.

The MCAT will be changing in 2015, and these changes are indicative of this new non-science trend. There will be a new section called Psychological, Social and Biological Foundations of Behavior. According to the AAMC, the addition of this section stresses the importance of socio-cultural and behavioral determinants of health and health outcomes.

Another major change in the medical school admissions is that schools are accepting more older and non-traditional students. In fact, about 30 percent do not take a traditional pre-medical path. The average age of medical students is increasing; not too long ago the average matriculation age was 22, and now it is 24. More students seem to be getting a Masters or PhD, or taking time off to work or travel before starting medical school.

The curriculum at most medical schools is also changing. Despite having to learn more material over the years, medical students are spending less time in lecture. This provides more time for independent study, research, and personal pursuits.

Clearly we are breeding a whole new class of doctors. So what does all this mean? Are our doctors going to be better or worse in the coming years? There is reason to believe that this new generation of doctors will better be able to relate to their patients. This is extremely important and will perhaps be more difficult to do because the patient population is also changing; patients are becoming older (due to aging Baby Boomers) and more racially and ethnically diverse. Therefore, we need our doctors to be more diverse (I mostly mean diversity of experience) and well-rounded. Students who take classes outside of the sciences are more well-rounded. As a result, they have lives outside of medicine, which will make them happier and less likely to be overwhelmed, which in turn will help them be better doctors. Furthermore, taking more non-science classes and pursuing other interests will allow doctors to better connect with their patients. I have experienced this while volunteering in the Emergency Department at the V.A. Hospital in Madison. One of the veterans I was helping told me about how he served under Patton during World War II. My education in history enabled me to have a great discussion with him. Another time one of the veterans made a reference to Joseph Heller’s Catch 22. I read the book in one of my previous literature classes, so I was able to converse intelligently with him. Connections between doctors and patients will bring them closer together, enhance the patient-doctor relationship, and make the patients feel more at ease during their time of suffering.

My only concern with this new class of doctors is that some have less education in biology and biological research. They may be better able to connect with their patients, but does this matter if they are not as capable of diagnosing and treating patients compared to past doctors, who almost all had strong science backgrounds and spent more time in lecture during medical school? This is a tough question to answer, but the strong science education that medical students receive should be enough to give them the tools they need to think like doctors and scientists and treat patients. Therefore, there is definitely reason to be optimistic about the future of medicine.

The Adventure Begins

Before I begin my blogging expedition, I will introduce myself. My name is Ryan Denu, and I just graduated from the University of Wisconsin-Madison with a BS in Molecular Biology. I will soon begin the MD/PhD program at the University of Wisconsin School of Medicine and Public Health (As an aside, I think it is so cool and very progressive for a medical school to incorporate as much public health education as Wisconsin does. I am definitely looking forward to this.). My hope is to become an oncologist and cancer researcher.

I decided it would be a good idea to start a blog after reading Atul Gawande’s Better. At the end, he offers bits of advice for people entering medicine, and one of them is to “write something.” Also, my girlfriend is an avid blogger (and a darn good writer I should add) and has inspired me. My goals for this blog are fourfold. First, I want to continue this blog or something similar throughout my entire career in medicine. Second, I hope that it will foster discussions among my fellow students and eventually my fellow doctors, professors, and scientists. Third, I hope to increase awareness about certain issues in medicine and perhaps inspire people to pursue solutions to some of these issues. Lastly, I hope that this blog will allow me to reflect and think through problems. Obviously these are somewhat lofty goals, but my philosophy has always been to aim high. I try to live by this quote from the English poet Robert Browning: “A man’s reach should exceed his grasp.” I may never achieve my goals, but the journey and the pursuit of these goals is enough.

The name for this blog came from my observation that the field of medicine is very ambiguous and characterized by much uncertainty. This uncertainty in medicine was also a major theme talked about by Gawande in Complications (I will probably reference Gawande a lot. He is an incredible writer, and I recommend all of his books).

As for content, I will be writing about trends that I see in the medical field and my responses to my experiences in medical school, research, and medicine. I am also interested in ethical issues in medicine and health care, so I will probably include posts pertaining to bioethics. Additionally, I am somewhat of a health freak, so I will probably write about nutrition and tips about healthier living that I come across. I am open to suggestions, discussions, and criticism, so please do not hesitate. I hope you enjoy reading.