316

Editorials Kindliness Is Next to Godliness Nor LONG AGO I was a member of an audience listening to a presentation on medical ethics, death, and dying. The message was to assure good, fair decisions. The speaker espoused "death with dignity." An older physician in front of me leaned toward a long-time colleague and muttered, "There's no such thing as death with dignity." I snapped to full attention. Surely death is not always a struggle. But many people, comfortable with having made plans for dispersing their goods and having said I love you and I forgive you and I cherish and respect you to important people in their lives, welcome the idea of dying in their sleep-on their own schedule. No one wants to linger; no one wants to linger in the disoriented way reported in one of the Lessons From the Practice appearing in this issue.I But wishes may not come true; fate may not honor preferences. How can physicians work toward assuring a patient's death with dignity, "dying in character," as Elisabeth Kiibler-Ross calls it?2 Several forces act distinctly against death with dignity. Although the use of technology presents great opportunities, it has unmistakable drawbacks. It can reverse downhill trends. It can foster a return to normal. It can make marvels. But it can also be unnecessary, uncomfortable, downright painful. It can prolong life, and death. Its beneficence can be countered by side effects and inappropriate use. The same is true for our impressive pharmacopeia. In addition, the fast pace of life and the ever-growing size and complexity of the health care system compound the impersonal brush-off that many patients feel as they are tossed in a churning current, seeking care. They long, as do we, for a still time, a healing time, a time when we can put into effect the implications of the Asian aphorism: We are given two ears and one mouth. Even during these turbulent times, there are beacons and anchors, principles to guide us. As we study, discuss, and debate biomedical ethics, we absorb concepts about patients' autonomy, about giving them choices and about respecting their choices. We also acknowledge the need for care that is whole and equitable and not based on the ability to pay or on social class. We are reminded that primum non nocere is a powerful directive, probably even more powerful than preventing harm and doing the right thing. Of course, we can assure the thoughtful use of technology and pharmacology. We can resist other forces that act against death with dignity by being sensitive to the oft-unspoken needs of patients. We can also add another litmus test to our armamentarium. This test may be the most important of all, yet it seems neglected in canons and weighty discourses. It is pure. It is personal. It is quiet. It is the test of kindness. Poets and playwrights, authors and philosophers have noted through the centuries that kindness brings warmth to the giver and the receiver. William Wordsworth valued "that best portion of a good man's life, his little, nameless, unremembered acts of kindness and of love."3 Robert Burns, a few years earlier, lauded "The heart benevolent and kind . most resembles God."4 Along with our capabilities, we need to develop our sensibilities. The challenge is to temper the wind to the shorn lamb. We have many strong "winds" -of machines and medications, of haste and distraction. We have many vulnerable

patients. Fortunately, we have ways to light our path, to lighten our path, to assure death with dignity. One is, be kind. LINDA HAWES CLEVER, MD REFERENCES 1. Watts WE, Watts DT: Denying the inevitable-The misplaced use of technology (Lessons From the Practice). West J Med 1992 Mar; 156:325-326 2. Kubler-Ross E: On Death and Dying. New York, Macmillan, 1969 3. Wordsworth W: Lines Composed a Few Miles Above Tintern Abbey on Revisiting the Banks of the Why During a Tour, line 33 4. Burns R: A Winter Night, lines 95 and 96

The Medical Waste Stream THE QUESTION OF WHERE and how to get rid of our solid waste is one of the latest issues to affect heavily populated areas of the United States. There are many background stories that have made headlines throughout the country and raised the issue as a major item on the political agenda. In the summer of 1987 a barge loaded with garbage from Long Island, New York, was refused entry at various ports of the United States and Latin America. The barge eventually went to New York City, where after considerable political wrangling its load was accepted for incineration. In 1987 and 1988 newspapers were filled with stories of medical waste washing up on beaches of various states along the coast. This adversely affected the beach areas' tourist trade. The movement to increase the regulations governing the disposal of medical and solid waste has been further accentuated by environmental concerns, such as the closure of many landfills, the dwindling capacity of others, the interstate shipment of garbage, and the difficulty of finding new sites for waste disposal facilities. Vociferous local opposition groups frequently prevented the establishment of new landfills or incinerators in their communities.1 In addition, some waste haulers have been charged with having organized crime connections or with restraint of trade through noncompetitive agreements. Some states have initiated licensing programs for waste haulers that require a police background check, comprehensive regulation of business practices, a policy of directing where and how the hauler will carry the solid waste, and a disposal fee and other taxes to fund an effective regulatory enforcement program. The cost inflation, the decreasing availability of alternate disposal sites, growing local opposition to changing solid waste management practices, health concerns about alternate disposal methods such as incineration, and fears about hazards perceived to be associated with medical wastes have increased political involvement. This has led to new laws and regulations that are designed to implement a cradle-to-grave regulated waste management program. Health and political concerns may result in especially stringent regulations to control medical waste.2 Federal regulations became effective on June 22, 1989, pursuant to the federal Medical Waste Tracking Act of 1988. The law directs the US Environmental Protection Agency (EPA) to establish a 2-year demonstration program for tracking medical wastes. The states of Connecticut, New Jersey, New York, and Rhode Island and the Commonwealth of Puerto Rico are participating in the program.3 The regulations list the medical wastes to be tracked and designate standards for separating, packaging, and labeling medical

THE WESTERN JOURNAL OF MEDICINE

MARCH 1992

3

317

wastes before sending them for treatment or disposal. The law also mandates a system of registration, recording, and fee payment for all generators. Institutions that generate more than 50 pounds of medical waste per month, such as hospitals, are subject to different regulations from those producing less waste, such as physicians. The demonstration program was completed on June 22, 1991, and the EPA evaluation will help determine whether such a program should be extended nationwide. It should be stressed that the demonstration program currently involves only regulated medical wastes generated in one of the states participating in the program. The federal law defines medical waste as ". . . any solid waste which is generated in the diagnosis, treatment, or immunization of human beings or animals, in research pertaining thereto, or in the production or testing of biologicals . In the decade 1979 to 1988 for the largest city in New Jersey, Newark, the amount of waste generated increased about 20% while the population serviced declined. In contrast, the cost of disposal increased more than 1,000%, and the rate of increase has been escalating in the last few years.4 This runaway cost inflation has occurred despite municipal development of management plans that included "maximum practicable use of resource recovery (recycling) and energy recovery." This inflationary trend is further aggravated by the fact that five states hold 34% of the nation's existing landfills (Reason Foundation, Los Angeles, Calif). The cost inflation has been especially severe in the northeastern section of the United States.5 While the standards and cost inflation have varied from state to state depending on local factors that affect disposal costs, the additional expenses and extra work associated with the disposal have affected all health care institutions and providers. While disposal costs have been increasing at a hyperinflationary rate, political, regulatory, and planning processes are being implemented to control the overall cost of medical services. An article in the New England Journal of Medicine stressed the need for the US medical care industry to reduce administrative costs to the levels seen in Canada. Dr Steffie Woolhandler estimated that administrative costs consume about 24% of total health care spending in the United States, or about $175 billion annually. In contrast, Canada spends only about 11% of its health care budget on administration.6'7 Waste disposal is a small but increasingly important administrative overhead cost. Physicians and medical care administrators must provide increased scrutiny to control these costs. Issues such as natural resources, the constant increase in the use of disposables, the newer nonrecyclable materials used in medical practice, and the entire spectrum of environmental political issues are having an effect on the medical care community. Medical care providers are beginning to realize that something must be done to reduce the volume of hospital and medical waste. We need to be better informed and more concerned about environmental effects associated with medical practice. Only recently have health care professionals begun thinking about the possibilities of using substitute products, of recycling, or of minimizing the use of disposable products. Gilden and colleagues, elsewhere in this issue, have suggested some means of reducing nonhazardous hospital waste and have recommended alternatives that save resources, reduce disposal costs, and conserve limited landfill space.8

The substitution of cloth for disposable diapers is one of the many proposed alternatives to reduce the waste stream. Manufacturers have tried to counter this with claims that their diapers biodegrade in a few years when disposed of in a landfill. The Federal Trade Commission on August 29, 1991, announced the signing of a consent agreement with a California company to cease advertising that its disposable diapers will break down in three to five years after placement in a sanitary landfill. This is the first case by the federal government involving claims that a product is biodegradable. Lee Peeler ofthe commission's advertising practices division stated it is "one of what we expect to be a series of FTC cases in the environmental claims area" ("California DiaperMaker Will Dispose of Environmental Claim," Newark Star Ledger, August 30, 1991). Health care professionals should plan based on cost and waste reduction factors as their predominant concerns. A manufacturer's claim is not necessarily based on fact. What we fail to do voluntarily and by example may be decided for us. Congress is expected to consider legal mandates requiring states to achieve specific recycling levels and to "beef up" government procurement preferences for products containing recyclable materials. There is also talk of a front-end national disposal tax (R. Scarlett, vice president, Reason Foundation, Los Angeles, California). The US health care industry is behind that of many other nations in learning how to manage our solid waste. A 1987 study by Inform, a research firm headquartered in New York City, revealed that Japan uses a three-pronged approach to its successful waste management system. Japan recycles more than 50% of its wastes, compared to just 8% in the United States. In Japan, each category of waste has an appropriate place, both in terms of environmental protection and in keeping waste management costs down; in the year of the study, 50% of all paper and 66% of all bottles were recycled. By comparison, the report stated the United States recycled only about 25% of its paper and 7% of its glass (G. Bishop, "Japanese Approach to Garbage Disposal Provides a Model for Jersey," Newark Star Ledger, November 12, 1987, p 33). Inform's study attributes part of Japan's success in managing solid waste to its "extraordinarily precise data on municipal solid waste generation, recycling, materials recovery, incineration, and landfilling" (Inform, "Japan Knows How to Handle Solid Waste," Bridgewater Courier News, December 14, 1987). The resource accounting system helps allocate capital, labor, and other expenses efficiently. We have made considerable progress since this report was published in 1987, but we have a long way to go. The medical care industry should take the lead in developing a system to reduce the quantity, environmental effects, and costs of our medical waste stream. It is important that physicians and medical care institutions develop waste management programs to more effectively control all wastes, including infectious, hazardous, and ordinary solid waste. Medical professionals must consider a new factor affecting how they function: environmental effects.

o

o

156

o

RONALD COHEN, PhD Health Officer Middle-Brook Regional Health Commission 1200 Mountain Ave Middlesex, NJ 08846

REFERENCES l. Cohen R: Impact of the solid waste crisis on medical practice. NJ Med 1988; 85:509-51 1

318 2. Martin C: Good news about medical waste. NJ Med 1985; 85:478 3. Managing and Tracking Medical Wastes. Washington, DC, US Environmental Protection Agency, Sep 1989 4. Sudol FJ, Zack AL: Urban recycling: Problems and solutions. NJ Municipalities, Apr 1988, pp 8-28 5. Dewling RT: New Jersey's solid waste crisis: What DEP is doing about it. NJ Municipalities, Feb 1988, pp 7,8 6. Woolhandler S, Himmelstein DU: The deteriorating administrative efficiency of the US health care system. N EngI J Med 1991; 324:1253-1258 7. Himmelstein DU, Woolhandler S: Cost without benefit: Administrative waste in US health care. N Engl J Med 1986; 314:441-445 8. Gilden DJ, Scissors KN, Reuler JB: Disposable Products in the Hospital Waste Stream. West J Med 1992 Mar; 156:269-272

Rational Approaches to Breaching the Blood-Brain Barrier SINCE PAUL EHRLICH'S remarkable observation that injecting

dye into the vasculature of mice deeply stained virtually all tissues while the brain remained pearly white, neuroscientists have been intrigued by the cellular mechanisms that mediate the selective transport of most nonlipophilic compounds into the brain parenchyma. The UCLA Interdepartmental Conference reported in this month's journal' identifies two important strategies that are currently being pursued in attempts to enhance drug delivery across this blood-brain barrier and into the central nervous system. The importance of such investigations is highlighted by two important themes. It is now clear that a much broader scope of central nervous system disorders than had previously been appreciated might be amenable to treatment with drugs. Also, technologies emerging from advances in molecular genetics and nucleic acid biochemistry are providing insight into the pathogenesis of affective, degenerative, and malignant disorders, which should identify novel targets for therapy and thereby require new agents that must enter the brain parenchyma if they are to be effective. The blood-brain barrier is a functional concept that encompasses physiologic, anatomic, and molecular dimensions. Typically, polar substances in the circulation are not taken up by brain tissue, and nonpolar substances pass into the brain in a manner that reflects their lipid solubility. The barrier is generally agreed to be located in the cerebral capillary endothelium, which is distinct from vascular endothelium found in other locations in that it is devoid of fenestrations. Also, adjacent endothelial cells are linked by continuous tight junctions, which are thought to be impermeable to the passage of all molecules. Astroglia may contribute to this barrier in that astrocytic processes are well documented to be very closely opposed to blood-brain barrier capillaries. Biochemical opening of the blood-brain barrier has long been examined as an approach to facilitate transport across the barrier, but even aggressive attempts at osmotically opening the barrier by infusion of hyperosmotic solutions has had disappointing results to date. Indeed, few disorders other than malignancy have been recognized as warranting the pursuit of such an approach, and ironically the barrier is invariably compromised within tumor parenchyma. Drugs apparently breach the barrier in these locations, although the interface of tumor and normal tissue and tumor cells that may have migrated away from the tumor mass remains an important problem whose consequences might be mitigated by techniques to open the blood-brain barrier. As described by Dr Keith Black, the availability of biologicals, such as leukotrienes, to enhance vascular permeability in damaged central

EDITORIALS

EDITORIALS

nervous system vessels associated with pathologic states such as malignancy raises the possibility of pursuing a biologically based strategy to selectively bypass the barrier. In this regard, identifying the physiologic mediators of vascular permeability in the central nervous system may give new opportunities for the design of novel pharmacologic agents to mediate transport across the blood-brain barrier. If vessels within the brain use different regulatory molecules from those important in the systemic circulation, it may be possible to regionally modify the barrier and provide a degree of specificity not previously anticipated for treatment with either antineoplastic or psychotherapeutic agents. A key feature of the blood-brain barrier is that it selectively inhibits the transport of hydrophilic molecules into the central nervous system. Such molecules cannot passively diffuse across the membranous design of the blood-brain barrier, and in recent years specific transport mechanisms that account for the physiologic transport of nutrients and other molecules, including glucose and amino acids, have been identified and characterized. One such mechanism, transcytosis, is discussed in the UCLA Interdepartmental Conference as the basis upon which novel approaches to the delivery of drugs to the central nervous system might be developed. Transcytosis is a specialized pathway of intracellular transport that may be shared by the blood-brain barrier and at least in part with other tissues such as epithelia. Like the barrier, many epithelial tissues consist of cells, linked by tight junctions, that must regulate the entry of molecules from the surface they line into the tissue upon which they sit. Transcytosis requires that the molecules to be transported be taken up at the cell surface, directed to the opposite cell surface, and released into the extracellular space. Clearly if hydrophilic molecules are to cross the blood-brain barrier, specific transport mechanisms consisting in some cases of carrier proteins and receptors must exist within the membranes themselves. Based upon biochemical and physiologic evidence, the existence of such transport systems has been hypothesized for a wide variety of molecules ranging in complexity from individual amino acids to complex macromolecules. As outlined by Dr Pardridge, molecules that are taken through the blood-brain barrier into the brain parenchyma by the process of transcytosis might be used as vectors to carry along therapeutically active molecules. For molecules such as glucose and transferrin, specific transporters have been identified. Other compounds such as cationized albumin traverse via absorptive-mediated transcytosis. Little is known of the molecular details that might provide insights into the precise mechanisms by which such ubiquitously expressed transporter systems might regulate entry into the central nervous system. Nonetheless, such systems may offer effective vehicles with which to breach the barrier. We are learning about the cellular pathways that mediate the directional transfer of molecules across polarized cells. Recent studies of epithelial tissue indicate the existence of specialized vesicular carriers that mediate the directional transport of proteins across cells and the identification of molecular signals, such as protein phosphorylation, that may mediate the selection of proteins for transcytosis, rather than some more common fate such as degradation or recycling. These studies provide evidence that an understanding of such details will enhance our potential for using either these systems themselves or pharmacologically manufactured agents that mimic the components of these pathways

The medical waste stream.

316 Editorials Kindliness Is Next to Godliness Nor LONG AGO I was a member of an audience listening to a presentation on medical ethics, death, and d...
774KB Sizes 0 Downloads 0 Views