Wednesday, July 25, 2007

An ethical and legal minefield for an ambulance service

Adrenalin (epinephrine) does appear to revive people so one can only speculate that this is some sort of bureaucratic quantification exercise

Heart-attack patients will be used as guinea pigs in a controversial medical trial proposed by the Queensland Ambulance Service. Paramedics attending to cardiac arrest cases will inject either a life-saving drug - adrenalin - or a placebo into the patient. Neither paramedic nor patient will know -- only the trial operators.

Adrenalin is used to make the heart beat if it has stopped. A placebo such as a saline solution, will produce no response in a patient suffering a heart attack. Medical experts said the idea of the trial was to evaluate the value of adrenalin in a cardiac arrests and potential side-effects, and was vital to achieving advances in medicine.

But it has been slammed by frontline ambulance officers. "Let's keep these trials out of the ambulance service and get back to concentrating on the basics such as adequate staffing levels and better response times," one paramedic said.

The University of Western Australia recently started a trial to "determine the efficiency of adrenalin on the survival of patients suffering cardiac arrest". The three-year-study was being funded by the National Health and Medical Research Council.

A spokeswoman for Queensland Ambulance Commissioner Jim Higgins confirmed interest here in the trial of adrenalin. The QAS has sought medical ethics approaal from Queensland Health to participate in this trial" she said. "It is not happening here yet. We don't have a timeframe for Queensland." The spokeswoman declined to elaborate further on QAS plans for the trial.

But one senior paramedic expressed outrage yesterday. "I don't think these trials have any place in an emergency pre-hospital setting," he said. "The patient would have no say in participating in such a trial - they are, after all, in cardiac arrest - and you have to ask yourself, `Would this be acceptable for a member of my family in cardiac arrest?' "The answer of course would be No. "I wonder how the Premier, Emergency Services Minister or Commissioner would react if a loved member of their family had a cardiac arrest and a paramedic turned up and started injecting something other than adrenalin, "This is inappropriate use of the ambulance service." The paramedic said that if the trial went ahead, some patients would be injected with a placebo that would not save their lives. "And the QAS would have sanctioned this in the name of a clinical trial," he said.

Details of the trial came to light after a Sunday Mail report last week- and revealed concerns by ambulance officers about a mix-up of drugs. Adrenalin had been "potentially" incorrectly labelled as pethidine or mixed with pethidine. The drugs have the opposite effect. Pharmaceutical supply giant Astra-Zeneca issued a nationwide recall last month, admitting "there is a risk to patient safety through administering an incorrect product". A batch of 75,000 ampoules of adrenalin imported from Britain was under question. One "rogue" ampoule was found at a hospital in NSW, which prompted the recall.

Queensland paramedics said the deaths of two patients - who were supposedly given adrenalin but did not respond - should be investigated. Queensland's Health Quality and Complaints Commission said it would look into the allegations. AstraZenaca's market access director Liz Chatwin said no other wrongly labelled ampoules had been found last week. Testing on the rogue ampoule had yet to be done by the Therapeutic Goods Administration.

The above article by Darrell Giles appeared in the Brisbane "Sunday Mail" on July 22, 2007

Dubious logic behind the proposed British "Fat tax"

Britain is in the midst of an epidemic of chronic ill-health and obesity. Something Must Be Done. Already, the school canteen has been the battleground for Jamie’s jihad on junk. Everything on the supermarket shelf must be labelled for calories, fat, salt and sugar so we can make ‘informed choices’. (And heaven help us if we make the wrong choices, because the National Health Service won’t.) And now the idea of making the ‘wrong’ foods more expensive - the so-called ‘fat tax’ - has been revived as a way of saving us from ourselves.

And yet, critics of the fat tax have generally failed to make the most important point about this latest wheeze: regardless of whether a ‘fat tax’ would have the desired effect of making some people eat healthier, we simply should not allow the government to micro-manage our lives in this way. We should tell the food- and fat-obsessed authorities to get stuffed.

Researchers from Oxford and Nottingham, writing in the latest issue of the Journal of Epidemiology and Community Health, looked into the possible effect of applying value added tax (VAT) to some items of food that are currently not subject to this tax (1). Using an economic model (actually an Excel spreadsheet), the researchers tested the effect of adding VAT to the main sources of saturated fat in our diets, like whole milk, butter, cakes and pastries, and cheese. They then went further and applied a scale of how ‘unhealthy’ a range of foods were, experimenting with their data to find out what would be the best way of applying the tax to decrease cholesterol levels and lower salt and sugar intake amongst the population. Based on various studies into cardiovascular disease in the past, they have concluded that an optimum application of VAT on fatty foodstuffs could avert ‘up to 3,200 cardiovascular deaths’ per year.

Their idea may have provided some food for thought - or fodder for phone-in shows at least - but the results of the report were not nearly as impressive as the news stories suggested. The researchers estimated that the total reduction in deaths from cardiovascular disease would be 1.7 per cent. Or, as the researchers themselves put it in their conclusions: ‘The potential changes in nutrition that would result from an extension of VAT to further categories of food would be modest.’

So modest, in fact, that the only sensible conclusion is not to bother with such a tax at all. The only reason that the researchers’ work generated such dramatic headline figures is that a large number of people die from cardiovascular disease in the UK. If you multiply this death toll by the tiny percentage the researchers found, you get quite an impressively high number of lives allegedly ‘saved’ by the tax. The problem is that in terms of any individual‘s risk from disease or ill-health, a ‘fat tax’ will make as much difference as urinating in the ocean.

Actually, it’s worse than that. The researchers treat the results of epidemiological studies as if they produced accurate measurements of the effect of a risk factor. However, correlation does not equal causation. There are so many confounding factors and built-in inaccuracies in such studies that to treat the figures produced as anything more than very rough estimates is totally inappropriate. Even a broad conclusion that X causes Y should only be drawn if the correlation is strong, consistent and biologically plausible (see An epidemic of epidemiology, by Rob Lyons).

The trouble is that when there have been big studies on the effect of changing diets, the results have been extremely disappointing. To give a recent example: in February 2006, a massive American study found that those put on a low-fat diet had the same death rates as those who ate what they pleased. As the lead researcher, Barbara V Howard, told the New York Times: ‘We are not going to reverse any of the chronic diseases in this country by changing the composition of the diet.’

The authors of the ‘fat tax’ report also make assumptions about how people might react to such a tax. They don’t believe that everyone will start eating salad and oily fish every day just because their usual fare is slightly more expensive. But they do believe that some people will change their behaviour a bit, enough to have an effect on disease rates. But what if they overestimate people’s sensitivity to such things? Perhaps people will react in unexpected ways: there’s evidence that many people react to such taxes by cutting down on ‘healthy’ food rather than junk, in order to balance their budgets. The results of a simple model of economic behaviour and the behaviour of people in the real world are two very different things.

So, it is far from clear that a ‘fat tax’ would work at all (3). But is it even legitimate to try to tinker with our food choices in this way? Many people point to the apparently similar case of applying swingeing taxes to cigarettes and alcohol. Yet, ‘health’ is often the spurious justification for taxes which are really more about balancing government budgets than improving the nation’s health. And if such taxes really did work, surely we would all be non-smoking teetotallers by now?

Efficacy aside, should we really allow the government to determine, through fiscal nudges and prods, how we choose to conduct our private lives? Who are they to tell us whether we should eat broccoli or burgers, chickpeas or cheddar cheese? It’s one thing for your parents to nag you as a child to eat your greens; it’s quite another for the health authorities to nag us when we’ve reached adulthood, and in the process to infantilise us all. Maybe campaigners for liberty should recognise that defending freedom in the twenty-first century will involve standing up for the freedom to choose what passes our lips as well as traditional issues like free speech.

A more active defence of our personal autonomy is a pre-requisite for maintaining a healthy body politic. Instead of a fat tax, the best thing would be to give the meddling health fanatics a big fat finger.



Just some problems with the "Obesity" war:

1). It tries to impose behavior change on everybody -- when most of those targeted are not obese and hence have no reason to change their behaviour. It is a form of punishing the innocent and the guilty alike. (It is also typical of Leftist thinking: Scorning the individual and capable of dealing with large groups only).

2). The longevity research all leads to the conclusion that it is people of MIDDLING weight who live longest -- not slim people. So the "epidemic" of obesity is in fact largely an "epidemic" of living longer.

3). It is total calorie intake that makes you fat -- not where you get your calories. Policies that attack only the source of the calories (e.g. "junk food") without addressing total calorie intake are hence pissing into the wind. People involuntarily deprived of their preferred calorie intake from one source are highly likely to seek and find their calories elsewhere.

4). So-called junk food is perfectly nutritious. A big Mac meal comprises meat, bread, salad and potatoes -- which is a mainstream Western diet. If that is bad then we are all in big trouble.

5). Food warriors demonize salt and fat. But we need a daily salt intake to counter salt-loss through perspiration and the research shows that people on salt-restricted diets die SOONER. And Eskimos eat huge amounts of fat with no apparent ill-effects. And the average home-cooked roast dinner has LOTS of fat. Will we ban roast dinners?

6). The foods restricted are often no more calorific than those permitted -- such as milk and fruit-juice drinks.

7). Tendency to weight is mostly genetic and is therefore not readily susceptible to voluntary behaviour change.

8). And when are we going to ban cheese? Cheese is a concentrated calorie bomb and has lots of that wicked animal fat in it too. Wouldn't we all be better off without it? And what about butter and margarine? They are just about pure fat. Surely they should be treated as contraband in kids' lunchboxes! [/sarcasm].

Trans fats:

For one summary of the weak science behind the "trans-fat" hysteria, see here. Trans fats have only a temporary effect on blood chemistry and the evidence of lasting harm from them is dubious. By taking extreme groups in trans fats intake, some weak association with coronary heart disease has at times been shown in some sub-populations but extreme group studies are inherently at risk of confounding with other factors and are intrinsically of little interest to the average person.


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