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Michigan Liberals Promote Abstinence-Only Education

A recent article in the LA Times reports on hazards associated with herbal sex aids.  This brings to mind a couple of reasons to be concerned about herbal products and dietary supplements. 


The full article (free registration required) has some valuable safety information about herbal products in general.  However, the author of this article missed two very important points, which I elucidate here. 

One, herbal products are highly variable in their contents.  Since they are regulated only loosely by the FDA, they may or may not contain what the marketer claims they contain; the amount of what they contain is likely to vary from batch to batch; and they may contain ingredients that are not listed.  The findings of the Canadian researchers are not unusual. There have been many cases of so-called herbal products containing synthetic drugs that ordinarily require a prescription.  There also have been cases of herbal products that contain nonpharmaceutical contaminants that are dangerous. 

Two, some herbal sex aids contain yohimbine.  Yohimbine is a naturally-occurring compound that acts on the alpha-2 receptor.  α₂ receptors are (presynaptic) autoreceptors that regulate the release of norepinepherine.  Yohimbine blocks these receptors, causing nerve cells to release more norepinepherine.  This raises blood pressure, and can cause extreme anxiety.  A pharmaceutical form is available; it contains a precisely measured amount of active drug.  Herbal preparations generally are not standardized, so it is impossible for the consumer to tell how much active drug is present. 

Note that some manufacturers  do  employ various methods to standardize their herbal products.  The Corpus Callosum recommends that, if herbal remedies are used, standardized preparations should be chosen. 

Herbal products containing aristolochic acid were recalled  because they are carcinogenic and nephrotoxic.  In April of this year, products containing ephedra were banned in the USA.  Ephedra is a naturally-occurring substance found in several plants.  It is chemically similar to epinephrine (adrenaline) and can cause high blood pressure, heart attacks, strokes, and seizures. 

A dietary supplement, L-tryptophan, was taken off the market after there were 27 deaths caused by eosinophilic myositis (eosinophilia-myalgia syndrome, or EMS).  L-tryptophan, a precursor of serotonin, had been found to have a slight antidepressant effect.  It also acted as a nonaddictive sleep aid.  Being a "natural" product, it became fairly popular.  Some psychiatrists started to use it to boost the effect of prescription antidepressants.  This practice was ended quickly  when the association between EMS and L-tryptophan was discovered. 

There are many instances of interactions  between herbal products, prescription drugs, and over-the-counter drugs.  Pharmaceutical products re not tested routinely for interactions with herbal products.  The Corpus Callosum recommends that anyone who takes a medication, and who is considering use of an herbal product, check with their pharmacist about the potential for interactions. 

On WebMD, there is a decent article  with recommendations for monitoring antidepressant treatment, especially for children and adolescents.  While I agree with much of the article, there are a few things I disagree with:


This notion -- that therapy helps people understand the roots of their depression -- is a common misunderstanding, in my view.  The statement implies that it is possible to know what the "roots" of the depression are.  Sometimes it is obvious; usually it is not obvious; and when it is not obvious, it probably is not possible to know what the roots are; at least with our current level of technology.  This is not to impugn the value of psychotherapy.  On the contrary, psychotherapy can be enormously beneficial.  I am skeptical, though, of any claim that we know how or why it works. 

As a philosophical aside, I think it is important to recognize therapy for what it is: an attempt to solve problems.  When first confronted with a problem, a natural response is to approach the problem by trying to figure out what caused the problem.  Sometimes that leads to a solution, but not always.  In fact, in the course of psychotherapy, it often is more helpful to understand what perpetuates  a problem, as opposed to what caused  it in the first place. 


I don't know who this Feinberg is, or what planet he is on, but on Earth, managed care has been a disaster for mental health treatment.  (Actually, I do know who Feinberg  is, and he has a good reputation.)  The hospital I work for terminated its contact with Blue Care Network, because they kept imposing unrealistic limits on coverage for mental health treatment.  One of the clinics I work at refused to renew its contract with Care Choices, for similar reasons.  I personally refuse to do business with Health Alliance Plan, because they impose such ridiculous bureaucratic obstacles to everything.  Years ago, I worked at an eating disorders program.  We had to close the program because of tightening insurance restrictions.  To be fair, managed care is not the only culprit, but I really don't see how Dr. Feinberg can say what he said.  Apparently, he had second thoughts himself, because his next statement was:


This is followed by:


Another perplexing statement.  Most therapists won't accept Medicaid, because it literally does not even cover the overhead in most clinics.  Washtenaw County Community Mental Health rarely provides psychotherapy to clients.  Another vexing aspect to insurance coverage is that most plans will authorize only a certain number of sessions, AND the number they authorize has to be split between the therapist and the psychiatrist.  So the more the patient sees the therapist, the less they can see the psychiatrist.  One could argue that this rarely poses a problem for patients with uncomplicated problems.  But the patients with uncomplicated problems usually don't see a psychiatrist: they get their prescriptions from their primary care provider. 

The title of the article -- Antidepressant Rx: Careful Monitoring Needed -- is good advice.  Careful monitoring is needed, for sure.  But the very structure of modern health insurance either makes that impossible, for many people, or makes it so difficult as to be impractical. 

The WaPo published an article on the abuse of medical records at Guantanamo. 

Detainees' Medical Files Shared
Guantanamo Interrogators' Access Criticized

By Peter Slevin and Joe Stephens
Washington Post Staff Writers
Thursday, June 10, 2004; Page A01

Military interrogators at the U.S. detention facility at Guantanamo Bay, Cuba, have been given access to the medical records of individual prisoners, a breach of patient confidentiality that ethicists describe as a violation of international medical standards designed to protect captives from inhumane treatment.

The files, which contain individual medical histories and other personal information about prisoners, have been made available to interrogators despite continued objections from the International Committee of the Red Cross, according to interviews and documents obtained by The Washington Post. After discovering the practice in mid-2003, the Red Cross refused to send medical monitoring teams to the facility for more than six months, sources said. [...]

This was commented upon by few bloggers.  Bete, at  Self-Indulgent Record of Idle Time,  copied the article to her blog without comment.  Based upon the context (the themes of adjacent posts) it appears that she is bothered by the report.  In contrast, Dr. Cori Dauber, on Rantingprofs, is troubled by the fact that some people are offended by the report.  Similarly, Greg, on Gregnews,  states:


Which view is "correct" ?  

Dr. Dauber's post is entitled "HERE'S WHERE I JUMP OFF THE BANDWAGON."  Excerpt follows:

Another stunning revelation in the on-going prisoner abuse scandal: medical personnel treating detainees at Guantanamo Bay have made detainee files available to interrogators.

Well apparently this just has all kind of very fine people very upset.

Are you kidding me? They're being held in detention because they're al Queda members and they're supposed to have the same privacy restrictions on their medical files as, oh, I don't know, people who don't blow people up as a career choice?

Cry me a damn river. I'm not kidding, I just don't care. Show the interrogators every scrap of information we get on these people.

We don't want them beaten? Excellent. I'm all in. But that means it's a psychological game between the interrogators and the detainees, and every single bit of information the US side -- anyone on the US side -- has available to bring to bear helps construct a strategy for that game. So long as they aren't actually denied appropriate medical care, and there's no evidence at all that's the case, go for it.

Apparently, she does not agree with these statements, from the WaPo article:


Ok, there are three experts in medical ethics who agree that the disclosure of medical records -- for the purpose of interrogation -- is unethical.  And one professor of Communication Studies, plus one nearly-anonymous blogger,  who think it is OK.  Dr. Dauber is entitled to her opinion, as is Greg.  I hasten to add that Dr. Dauber includes some things in her post that I agree with.  But she is wrong to state that interrogators should have access to medical records.  The fact that there is no established international law governing medical confidentiality is immaterial.  (Our Administration has nothing but contempt for international law; so even if there were such a law, it would be no deterrent.)  The problem with giving interrogators access to medical records has to do with medical ethics, most of which are traditional, not legal. 

In daily practice, it is common for me to get requests for medical information, and I refuse to give it.  When I do so, I invariably get a ream of paper over the fax machine that points out that the request is legal.  I invariably send a note back to the insurance company/employer/attorney, saying something like "OK, maybe it's legal, but it also is unethical." 

For a medical professional to turn over records, to the detriment of the patient, can be permissible under narrowly defined circumstances.  The circumstances vary, but in all cases, there is a due process involved.  This often involves judicial oversight, duly constituted administrative oversight, or at least a carefully worded bit of legislation that clarifies the exact circumstances in which disclosure is necessary.  For example, if a patient tells a medical professional of a credible plan to kill or seriously harm an identified third party, the doctrine of duty to warn  is invoked.  I've done this myself a few times, and I agree that it is a valid legal principle. 

One might argue that, in wartime, it is OK to bend the rules:  If it is permissible to warn someone based upon the content of certain privileged information, perhaps we could extend that a little bit, and use privileged information to find out if a danger exists.  This, obviously, would be analogous to abandoning the doctrine of probable cause.  The principle of probable cause is one thing that keeps us from being a totalitarian state.  Giving this up would be extremely dangerous.  The US government is more powerful than any terrorist organization, and it needs to be constrained.  Moreover, and more to the point, medical knowledge is dangerous, and generally should be limited to benevolent purposes.  If there are to be exceptions, as with the duty to warn, these exceptions should be delineated in a democratic forum. 

It is ridiculous to say that exceptions are appropriate just because we are in a War on Terrorism.  It is disingenuous to imply that bending the rules is OK because we are in an exceptional circumstance.  Terrorism will never go away.  Thus, any "exceptions" will not really be exceptions; they will be the new standard operating procedure.  If we want to change our standard procedure, well, let's do that; but let's do it with a clear understanding that it is not because of an exceptional circumstance. 

There has been a fair amount of blogbuzz lately, about the subject of nuclear power: not the type of power that comes from having really big bombs, but the type of power that is used to generate electricity.  There are posts on the subject at Crooked Timber, Tapped, Mark A. R. Kleinman, Washington Monthly, and Brad DeLong's Semi-Daily Journal.  These posts generated a lot of comments, but not a lot of technical information is present in the original posts or in the comments.  Several comments included requests for more information.  On the weblog Too Many Worlds, William Kaminsky (a PhD student in the Physics Department of MIT) responds to some of the requests for more information on the subject. 

As it happens, I used to work at a nuclear research reactor.  This alone does not make me qualified to provide technical information, but the experience did make me a little more receptive to the idea of nuclear power.  At least I don't dismiss the idea automatically.

In this post, I provide links to some additional sources of information about nuclear power, add my own thoughts on the subject, and attempt to sharpen the focus of public discussion. 

It is important to recognize the fact that there are two main areas of discussion: the technical aspects of nuclear power, and the public policy aspects. 

Regarding the technology, a good set of links to technical information is at IDEA Nuclear Science Information.  The journal, Nature, has a good review  of the latest technical developments; unfortunately, a subscription is required to view it.  Much of the information in the Nature paper can be found elsewhere.  The key phrase to search for is "Generation IV International Forum" known by the acronym, GIF.  Generation IV is the fourth generation of nuclear power plant designs.  The GIF is a consortium of ten countries that has been meeting to reach consensus on the most promising new designs.  An understandable summary of these designs can be found here.  Some may find the design details to be boring, but people who like reading about technology will be interested.   For reference, there is a concise explanation of some key concepts is here. 

The basic idea is that future plants will have to operate at high temperatures in order to increase efficiency.  The increased efficiency is necessary to reduce waste generation and to decrease the cost of the energy produced.  Note that, as a side benefit, some of the designs produce heat that could be used in industrial processes; and some could be adapted to produce hydrogen.  They also can be used for desalination of ocean water.  All of the new designs include planning for management of the nuclear fuel and radioactive waste. 

The last point mentioned is a critical one.  It seems to me that in the early history of nuclear power generation, there was not sufficient planning for the production, transportation, and disposal of radioactive fuel.  Most of the Generation IV designs have incorporated a capacity for recycling of fuel.  This helps minimize the need for transportation of radioactive material.  Whether it would be cost-effective depends upon the price and availability of uranium ore, as well as the cost of disposing of spent fuel.  

The ability to produce hydrogen could turn out to be an important benefit.  The themochemical reaction made possible by high-temperature operation produces hydrogen and oxygen, without producing carbon dioxide.  SInce the hydrogen is a good energy source, the production of hydrogen results in an increase in the net efficiency of the operation.  It also avoids the environmental problems associated with producing hydrogen from fossil fuels. 

Turning now from the technical to the policy issues, there is a short, freely-available review of the public policy issues pertaining to nuclear power is a paper that is on-line at the Belfer Center for Science and International Affairs.  The author states that he is not advocating for or against nuclear power; rather, his intent is to clarify the reasons for nuclear power to be a significant issue, and to highlight some important safety issues. 

Enabling A Significant Future For Nuclear Power:
Avoiding Catastrophes, Developing New Technologies, Democratizing Decisions -- And Staying Away From Separated Plutonium
Matthew Bunn


Dr. Bunn's paper was written in 1999, which, obviously, was before 9/11/2001.  Even so, terrorism and nuclear proliferation are prominent themes in his paper.  Indeed, all the the Generation IV designs include consideration of antiterorrist hardening.  That is, even though the paper is old (by standards of modern technology) the policy issues still are current.  Read the whole thing if you want, but his main point is that, in order to reduce the risk of nuclear proliferation, reprocessing of nuclear fuel should be avoided.  He advocates what he calls a "once-through" fuel cycle. 

Another point Bunn makes is this:
The implication is that careful, unbiased study is needed prior to making any major policy decisions.  The Belfer Center has a more recent report, The Future of Nuclear Power, (dated July 2003) that is available as a PDF download.  The whole thing is over 29 Megabytes, though.  The summary (350Kb) is here.

The authors share Dr. Bunn's view that a once-though fuel cycle is desirable.  They also suggest that limited government subsidies may be appropriate.  The notion of government subsidies is a point of contention used by antinuclear activists, and it is not popular with those who tend to advocate pure free-market economic policies.  They also recommend streamlining regulatory functions: sure to be popular with the industry; sure to meet with skepticism from the public.  They raise some important safety questions.  They advocate for an expanded role for the IAEA (website link), including giving them the authority to inspect all "suspect" sites. This could include inspections within the USA.    They favor the development of only one of the Generation IV designs: the very-high-temperature gas-cooled reactor (HTGR).  In short, everyone will find at least some recommendations that they dislike. 

The authors of The Future of Nuclear Power  do not necessarily advocate expansion of nuclear power generation:

• increase efficiency in electricity generation and use;
• expand use of renewable energy sources such as wind, solar, biomass, and geothermal;
• capture carbon dioxide emissions at fossil-fueled (especially coal) electric generating plants and permanently sequester the carbon; and
• increase use of nuclear power.

Adding 1000 nuclear power plants would require a massive effort and equally massive investment.  The need for this many reactors is based upon the premise that one of the goals is to reduce CO2 emissions.  The authors of the report think that we should try to preserve the option of using nuclear power, specifically because of the importance of carbon dioxide in the genesis of climate change:

Today, nuclear power is not an economically competitive choice. Moreover, unlike other energy technologies, nuclear power requires significant government involvement because of safety, proliferation, and waste concerns. If in the future carbon dioxide emissions carry a significant “price,” however, nuclear energy could be an important -- indeed vital -- option for generating electricity. We do not know whether this will occur. But we believe the nuclear option should be retained, precisely because it is an important carbon-free source of power that can potentially make a significant contribution to future electricity supply.

In my view, this raises an important question, one that they do not address: is it already too late for us to make good use of nuclear power?  It is my opinion that the nuclear power industry, in the last half of the twentieth century, was overly complacent about the ability to technological advances to solve serious problems with nuclear power.  They raced ahead to build power plants even though there had not been adequate research into materials science and fuel cycle technology.  They assumed that any problems that emerged could be solved later.  They found out -- after many reactors already were in operation -- that some of the materials they were using could not withstand the torturous environment of a nuclear reactor.  They also found out that there are enormous political and technical problems with short-term and long-term waste storage.  In retrospect, they would have been better advised to go at a slower pace. 

If a slow pace is necessary for safety reasons, how feasible is it going to be to build 1,000 nuclear power plants by mid-century?  A smaller number will not have sufficient effect on climate change.  Yet, the worth of the entire endeavor is predicated upon the potential for nuclear power to reduce the risk of climate change. 

The implication of this argument is that it may already be too late for us to make good use of nuclear energy.  If climate change is not a concern, then nuclear energy is not economically viable.  If it is a concern, then we need to build a lot of reactors quickly in order to make a difference.  But if we build a lot of reactors quickly, we may run into serious safety problems.

I will accept their main recommendation at face value: we should try to preserve the option of nuclear power.  They state that this would entail increased R&D spending of about $400 million per year for the next five years, and $460 million per year for five years after that.  The Nature  article indicates that actual construction of a Generation IV facility would be about one billion dollars.  This would mean spending $4.3 billion on R&D, then another billion to build the first reactor. 

To put that into perspective, we have already spent that much on the construction and operation of our newest aircraft carrier -- the USS Ronald Reagan (CVN 76).  The benefits of nuclear power R&D would be much greater than the benefit of a new aircraft carrier.  Just decreasing the risk of nuclear proliferation will do more to ensure our safety than one of those boats ever will. 

Keep in mind that other countries, especially China and France, are going ahead with nuclear power regardless of what US policymakers have to say.  Even if we never build our share of those 1,000 reactors, other countries are going to build theirs.  This being the case, it is in our interest to be sure that there is adequate research into the various safety issues.

I think, though, to get the most out of the R&D effort, it should be conducted in a way that maximizes the likelihood of finding new materials and new technologies that could have uses outside of the nuclear industry.  Furthermore, the research efforts should be designed to increase international cooperation and provide mutual benefit to all countries that participate.