Boreal B[l]og

“…any man’s death diminishes me, because I am involved in mankind.  And therefore never send to know for whom the bell tolls; it tolls for thee”  (John Donne)

“Pneumonia is the friend of the elderly.”

“That’s what Meredith says happened to her mother. Though she received $40,000 worth of care in her last two months of life, not one of her 25 doctors sat down with Dorothy Glas and her family and discussed how she wanted to die.”

If Islamic terrorists shot down a plane with 400 people on board, we would have the country’s airspace shut down, fighter jets guarding our airspace, and the economy would suffer a huge blow.  Since June, that many women have died at the hands of a man they knew.  Not much outrage.  Since early August, that many children have died because of firearms. No outrage.

As I write, Ebola, with a death toll of 1 in the US, has caused pilots not to show up to fly, schools to close, and people to buy biohazard suits.  This is the “home of the brave”? The facts: at the time of writing, the 3-week quarantine for people who treated the index case in the emergency room has quietly ended. No other cases have occurred.  Ebola has dominated the news, with a large number of articles, posts, political cartoons, demands to “do something,” stop all travel with West Africa, which is a large area, most of which is not infected with Ebola.  It is worth looking at a map of Africa some time.  The continent is 50% larger than North America.  Two thousand languages are spoken.  Worrying about “West Africa” is like worrying in Portland, Maine for a problem in Atlanta.

I am not getting to my point soon enough.  Twenty thousand people a year commit suicide in the US using firearms.  I am not talking about murders, which are about eleven thousand.  But hey, to misquote Stalin, a single death is a tragedy and a million are a statistic. We tolerate similar carnage on our highways.  A young couple and their 7-month old died on US 20 the other day near Santiam Pass following a collision with a larger vehicle. It wasn’t Ebola, so there was no outcry.  But they are still dead.  There is no way we can prevent all these deaths, but we ought to do better.  Seventy-three thousand people go to emergency departments with gunshot wounds (GSWs) every year.  The current congressional representative from Tucson, Ron Barber, whom I know, walks with a limp, for he was shot at the “Tucson Massacre” in 2011, where his predecessor, Gabby Giffords, whom I also know, was severely injured by a GSW through the parietal lobe.  Her remarkable recovery, sadly incomplete, is inspiring.  A crazy man with a gun did that.

Ron has to campaign supporting the Second Amendment, even though he was a casualty of the fact that the Second Amendment apparently has no limits in the US, at least if one wishes to get elected.

Fact: the number of homicides per 100,000 people has fallen 50% since 1993.  This, however, has not been the case with suicides. Many of us think gun violence has increased.  It hasn’t.  It is still too high.  One is too high.  Suicide is the 10th leading cause of death, and firearm use in suicides accounts for more than sixty per cent of all firearm deaths.  Firearm deaths are a public health issue far exceeding Ebola, four times that of ALS, and fifty times that of Cystic Fibrosis.

Why would the NRA, therefore, through its influence in the Senate, try to block a Surgeon General’s nomination, who believes that firearm violence is a major public health issue?  Isn’t it? If a death from Ebola is major, what about twenty thousand a year from firearm suicides?  Is that not a public health issue?  Sure, a determined person who wants to die will find a way, but many suicides can be prevented.  We know this. The availability of firearms makes suicide a lot easier.  What about homicides, especially the women who die from being murdered by their husbands or boyfriends?  Why do we panic over Ebola but are so silent when it comes to men killing women and people killing themselves with firearms?

Come to think of it, on 60 Minutes, a doctor expressed outrage at Oregon’s Death with Dignity Act (DWDA), because he called it assisted suicide.  We call it “hastening” here.  Hey, they use their words, and I will use mine.  The DWDA was voted in twice by Oregon voters, despite political action by the Catholic Church (they should have lost tax-exempt status), upheld by the Supreme Court, and accounted for exactly 112 deaths in Oregon last year. The major reasons people choose hastening is not because of pain, which is still poorly treated, and the Dartmouth physician should be addressing that, but because all are terminal and have had enough. Here are their major reasons:

Losing autonomy  (93%)

Less able to engage in activities making life enjoyable  (89%)

Loss of dignity  (73%)

All 112 were going to die in a few months.  They wanted to choose when and how.  They were not depressed, as was alleged; 2 last year required psychiatric evaluation, and as a neurologist, who diagnosed depression long before the diagnosis was “mainstream,” I have some idea of what I am talking about.  No, these people had enough.  When one stood in front of the mirror one morning, after having lost 40% of his body weight, likened himself to an Auschwitz survivor, he had seen enough.  He knew what was coming, and he wanted to be in control.

Public health issues?  There are many.  Firearms are one, and the NRA is wrong to recommend against a Surgeon General nominee who understands that.  We can easily fix Ebola, and DWDA is what most people want to have an option. If you don’t believe me, volunteer at a nursing home some time, where demented people get their pneumonia treated, so they can go back to the same existence.

Finally, every adult, and let me repeat, every adult, needs a living will.  Young people can be brain damaged from accidents and they can get cancer, too.  Be very clear on what your end of life desires are.  You do have choices.  You can make choices I may not.  That is your right.

I don’t want my pneumonia treated, should I become demented.  It will be my friend.

I didn’t start it, but I did finish it.

My wife and I took an early morning shuttle to the Minneapolis airport after our annual weeklong trip into the Boundary Waters.  Coming out of the woods after a trip requires readjusting to a lot of people and noise.  We had been been in a world where nature ruled.  It is not inherently dangerous in the woods, if one can read the weather, understand animal behavior, and constantly observe the surroundings.  There isn’t any right or wrong out there, only consequences.  We’d do well to heed that aphorism in nature today.

The other passenger was a woman from California’s central valley, who began a conversation with the shuttle driver about the drought.  The conversation soon devolved to the smelt, a fish that had been protected for years, but whose protection now cost sending water to farms.

After hearing “tree huggers”, I then heard her say “people have priority over fish.”  The fish had been protected by people, so I wasn’t following her reasoning.  The fish doesn’t have a choice but to live in water; people have the choice to control their numbers and use water properly, especially in dry areas, like the central valley.  Nature doesn’t tell us to control population or water use, but there are consequences if we don’t. The lady then referred to herself as “an environmentalist.”

I was beginning to seethe but held my tongue, as we would soon disembark.  My wife, however, who usually stays quiet, commented, “Some of us back here feel differently.”  Her words ignited me.

“Perhaps if California had a better system to allocate water and acted a lot earlier, this wouldn’t be a problem,” I began.  “Perhaps we shouldn’t try to grow certain crops in places where the rainfall is capricious.  If Fresno used the same water per capita as Phoenix, 3/4 million acre feet would be saved annually. Half the houses in Sacramento don’t have water meters.”  I had a dozen more things I wanted to say, including rainwater harvesting, fixing leaks, not brushing teeth with the faucet running, and 90-second showers, but we were at the airport.

“There are two sides to every story, I guess,” the woman replied.

“Yes,” I shot back.  “Facts and unsubstantiated opinions.”

That ended the discussion.

I don’t bring up controversial topics in places like airport shuttles.  But if they are mentioned, I may add my two cents’ worth.  What annoys me about the “two sides to every story” argument is many assume both sides are telling the truth.  They aren’t.  We have become a society where everybody’s say is equal to everybody else’s, and if Fox News wants to lie, it can, without consequences.  In 2014, we still allow equal time to those who believe the Earth is 10,000 years old, or that the highest carbon dioxide levels in humanity’s history have no consequences.  A large percentage of Americans feel there is no climate crisis, because enough doubt is interjected by the other side, especially by those who are good looking, sound sincere, misuse statistics, or just yell and bully— all are effective—to make their case.  We shouldn’t be debating evolution or the climate in 2014; animals are already evolving—or going extinct—because of us.  We should be trying to develop workable solutions to major problems.

I am disturbed by those with influence—I will use Sen. John McCain, for example—who violate their duty to use such influence wisely.  Mr. McCain has said many things I have disagreed with during the two decades I was his constituent.  His coming to my new state, Oregon, to campaign against a sitting Senator, once considered unethical by the Senate, bothered me.

What McCain said would have been laughable if so many people didn’t believe it.  He said that challenger Dr. Monica Wehby would be the “go-to” person to fix the VA System, since she had experience with the VA.

Mr. McCain voiced unsubstantiated opinions.  Here are facts:  Dr. Wehby is a pediatric neurosurgeon who had some of her training at the VA, like every other doctor, including me.  How many pediatric patients are at the VA?  None, unless we are conscripting kids for our several wars.  I too, trained at the VA, both as a medical student and as a neurology resident.  I saw patients. I did not know anything about running the system, and in my unsubstantiated opinion neither did Dr. Wehby. Fact: nobody with whom I trained had that experience. Fact:  Dr. Wehby has had two restraining orders placed on her by men.  That doesn’t disqualify her from the Senate, but at at time when we are polarized, her presence isn’t likely to help. That’s an opinion from one who studied psychiatry (a fact), along with an opinion that two restraining orders suggests an individual has serious anger issues. It is possible to be a good neurosurgeon yet a poor senator.  Opinion.

Fact:  Dr. Wehby is a physician running for the Senate.  Her medical training actually makes her less likely than the average physician to deal with health care finance, because she is highly specialized and less exposed to insurance issues than the average FP.  Fact.

I remember the last well-known physician-senator, Dr. Bill Frist, who also campaigned against Sen. Tom Daschle in South Dakota.  Frist had the absolute gall to say that Terri Schiavo was clearly conscious, on the basis of a video, because she laughed, when the late Ms. Schiavo was in a persistent vegetative state, a fact, where automatic smiling may occur, like in babies.  Fact: The American Academy of Neurology filed an amicus curiae brief with the Florida court, and Ms. Schiavo’s brain at autopsy weighed 600 gm, the least in an adult I ever saw as a neurologist.  Fact: I saw many brains at autopsy and cut brains to teach anatomy to the nursing staff at the hospital where I practiced.  Fact: Congress was called back for an emergency session in March 2005 to block Mr. Schiavo’s wishes to stop support.  Fact: some physician-legislators who were not neurologists weighed in with opinions without ever examining Ms. Schiavo.  Fact: I was a fellow of the AAN who had dealt with many vegetative cases in my career and supported the ethicists in the AAN who did examine Ms. Schiavo.

Yes, there are two sides to every story, but they are usually not equal.  We aren’t tossing a coin here, with a 50% probability of heads; we are dealing with the smelt, fresh water allocation, the climate, who runs the country, war, Ebola, overpopulation, the Earth’s age, and resource degradation.  We should be using science, models, and probabilities.  The probability that the Earth is older than 10,000 tropical years is 1. The confidence we have that manmade climate change is occurring is over 95%. Fact. California cannot continue to use water the way it once did.  Fact.  Unsubstantiated opinion:  America needs decisions made less by charisma and screaming and more by science and careful deliberation.

Fact: Soon.