Saturday, April 30, 2005

60 years ago today: The end of the Führer

Sixty years ago today, the capital of the thousand year Reich, Berlin, was in ruins, after only twelve years of the Nazi regime. For months, it had been pounded from the air by Allied bombers, and now it was being pounded relentlessly by Soviet artillery, bombers, and tanks. Berlin was completely circled by its enemies, who even now were advancing to within artillery range of the Reichstag itself, lobbing shells that were exploding close enough to shake the building. Remnants of the German forces fought a desperate, last ditch defense, even though they were outnumbered and outgunned, with no hope of doing anything more than slowing down the inevitable onslaught by a few days or hours. Adolf Hitler's dream of creating a Reich that would endure for a thousand years, obtaining Lebensraum in the East for Germans to expand into, enslaving the "inferior" Slavs of that land, and destroying Bolshevism, a dream that had plunged the world into war and led to the deaths of millions, both in combat and in the planned slaughter of six million Jews that later became known as the Holocaust, had backfired spectacularly, plunging Germany into nightmare. Not only had he failed to destroy Bolshevism, his gamble in launching a two-front war had led to the destruction of Germany, the deaths of hundreds of thousands German civilians and soldiers, and the mass rape of German women in the East by soldiers in the advancing Red Army. His most hated enemy had allied itself with nations that he had only half-heartedly gone to war with, Britain and the United States, and the combination was too much to overcome. Although Hitler could not know it at the time, his folly had not only delivered the eastern half of Germany into the hands of his most hated enemies, but that domination would last 45 years, nearly four times as long as the Third Reich had endured.

In the bunker below the Reichstag, it was becoming increasingly obvious that it would not be very long at all before the Russians would reach the grounds of the Reichstag itself; within days, if not hours. In the days and weeks leading up to April 30, the mood in the bunker had become increasingly surreal. Hitler issued orders for counterattacks and attempts at breaking the stranglehold the Soviets were developing on Berlin to armies that no longer existed. He pondered models of the intended postwar rebuilding of his hometown of Linz, to which he said that he wished to retire after the war. When news of Frankin D. Roosevelt's death reached the bunker on April 12, Hitler had become jubilant, seeing the death of his enemy as a sign that the Reich's deliverance was at hand, that his enemies would collapse. It wasn't.

On April 20, Hitler's 56th birthday was celebrated, but the atmosphere was more funereal than celebratory. Hitler clearly saw the celebration of his birthday with his enemy well into the maneuver of completing its encirclement of Berlin as profoundly embarrassing, as did the few remaining loyalists in the bunker. Hitler did emerge from the bunker, climbing the stairs to the Reich Chancellery park. Greeting him with the raised arm "Heil Hitler" salute were soldiers from the SS-Division "Berlin" and twenty boys from the Hitler Youth who had distinguished themselves in combat. The whole scene reinforced the hopelessness of the situation. The defense of the Reich capital, relying on boys? However, it was a natural consequence of Hitler's all-or-nothing thinking. To him, it would be either victory or utter destruction, and if that meant throwing boys into combat against battle-hardened Soviet troops with vastly superior firepower, so be it. As he had raged before, if Germany failed then to him it deserved utter destruction. Two days later, at a briefing, Hitler learned that Soviet troops had broken through the inner defenses and were now moving through Berlin's northern suburbs. Hitler was told that an ordered counterattack had never taken place at all. At this news, the reality of the situation finally seemed to sink in, and Hitler snapped. Hitler screamed that he had been betrayed by all whom he had trusted, railing against the treachery of the army and claiming that the SS was lying to him. The troops refused to fight, and all defenses were down.

And then he stopped. He slumped in a chair and cried. The great dictator, the man responsible for starting a world war and who had callously ordered the murder of millions of innocents, sobbed. The man who had expressed no concern over the suffering of his people, and whose "scorched earth" war orders designed to resist at all costs and destroy infrastructure rather than let it be used by the Soviets (some of which had been secretly undermined by Albert Speer and various industrialists, who did not want to increase the suffering of the German people more) cried. He sobbed that the war was over. He vowed that he would stay in Berlin and lead the defense of the city. Then, rather than allow himself to be captured he would at the end kill himself. All urged himself to change his mind, to make an attempt to break out and retreat to his mountain redoubt of Berchtesgaden, there to continue to lead the resistance. His apocalyptic Wagnerian vision of Gotterdamerung would be fulfilled.

The situation continued to deteriorate, and several in the bunker left, preferring to take their chances trying to escape capture or to die in the open, rather than being trapped in the bunker. When Hitler learned on April 28 that one of his most trusted deputees, SS Chief Heinrich Himmler, had made peace overtures, it was the final straw, and Hitler went into one more monumental rage. On April 29, Adolf Hitler had married Eva Braun, exchanging vows in a simple ceremony. She had vowed to stay in the bunker with him, and would soon die with him. His last will read:
As I did not consider that I could take responsibility, during the years of struggle, of contracting a marriage, I have now decided, before the closing of my earthly career, to take as my wife that girl who, after many years of faithful friendship, entered, of her own free will, the practically besieged town in order to share her destiny with me. At her own desire she goes as my wife with me into death. It will compensate us for what we both lost through my work in the service of my people.

What I possess belongs - in so far as it has any value - to the Party. Should this no longer exist, to the State; should the State also be destroyed, no further decision of mine is necessary.

My pictures, in the collections which I have bought in the course of years, have never been collected for private purposes, but only for the extension of a gallery in my home town of Linz on Donau.

It is my most sincere wish that this bequest may be duly executed.

I nominate as my Executor my most faithful Party comrade,

Martin Bormann

He is given full legal authority to make all decisions. He is permitted to take out everything that has a sentimental value or is necessary for the maintenance of a modest simple life, for my brothers and sisters, also above all for the mother of my wife and my faithful co-workers who are well known to him, principally my old Secretaries Frau Winter etc. who have for many years aided me by their work.

I myself and my wife - in order to escape the disgrace of deposition or capitulation - choose death. It is our wish to be burnt immediately on the spot where I have carried out the greatest part of my daily work in the course of a twelve years' service to my people.

Given in Berlin, 29th April 1945, 4:00 a.m.
[Signed] A. Hitler
In another document, his last political testament, he dictated to his young secretary, Traudl Jung:
It is untrue that I or anyone else in Germany wanted war in 1939. It was desired and instigated exclusively by those international statesmen who were either of Jewish descent or who worked for Jewish interests. . .Centuries will pass away, but out of the ruins of our towns and cultureal monuments the hatred will ever renew itself against those ultimately responsible whom we have to thank for everything, international Jewry and its helpers.
Regarding the Holocaust, he obliquely but chillingly wrote:
I also left no doubt that, if the nations of Europe are again to be regarded as mere blocks of shares of these international money and finance conspirators, then that race, too, which is really guilty of this murderous struggle will be called to account: Jewry! I further left no one in doubt that this time millions of grown men would not suffer death, and hundreds of thousands of women and children not be burnt and bombed to death in the towns, without the real culprit haivng to atone for his guilt, even by more humane means.

The remainder of his testament was devoted to ramblings about a "renaissance" of National Socialism and the charade of nominating a successor government. His final charge to the successor government:
Above all, I charge the leadership of the nation and their subjects with the meticulous observation of the race laws and the merciless resistance to the universal poisoner of all peoples, international Jewry.
[Source: Hitler 1936-1945: Nemesis by Ian Kershaw]

Even there, at the end, he could not release his hatred and wanted his successors to continue his persecution of the Jews.

Finally, in the afternoon of April 30, after taking lunch as usual with his secretaries, Hitler retired to his study with Eva Braun. Hitler's followers waited. And waited. No one heard a shot. Finally, according to accounts by Major Freytag von Loringhoven, Traudl Jung (Hitler's staff secretary, and subject of the documentary Blind Spot: Hitler's Secretary) and SS Staff Sgt. Rochus Misch, one of Hitler's bodyguards, Hitler's vale, Heinz Linge, got up the courage to look inside the room, and found Adolf Hitler and Eva Braun dead, Hitler having shot himself as he bit on a cyanide capsul, and Braun having taken a cyanide capsule. His remaining followers carried the bodies into the courtyard of the Reichstag, doused them with gasoline, and set them ablaze. In the meantime, Magda Goebbels poisoned herself and her six children with the help of SS doctor Helmuth Kunz.

Thus ended the life of one of the scourges of the 20th century. Rumors that Hitler had never died continued for decades, mainly because the Soviets never acknowledged that they had found Hitler's remains until relatively recently, when they put a fragment of Hitler's skull on display.

In the 60 years since today, Hitler has come to take on many meanings, with different meanings to different people. To many, he is the utter embodiment of implacable hatred and evil. Indeed, to some, he is almost not human, and books or movies that portray him as anything other than a monster cause controversy, even today. For example, consider Downfall, a recent German film based on Joachim Fest's book The Downfall: Inside Hitler’s Bunker. This film portrays the last days in the bunker and has been criticized for "humanizing" Hitler, who, as portrayed by Bruno Ganz, comes across alternately as kindly and raving.

Is it wrong to "humanize" someone who was responsible for so much death and destruction.

I don't know the answer, but Hitler was human, and denying it or criticizing portrayals of him as anything other than a raving monster contributes nothing to understanding how one man could perpetrate such evil. Obviously, he was a baby at one time. Indeed, there is a photo of him as a baby on the cover of Ron Rosenbaum's book Explaining Hitler: The Search for the Origins of His Evil, perhaps the best book written thus far to examine what Hitler means to different people and different explanations for the origins of Hitler's evil. It is rather haunting. In Ian Kershaw's biography Hitler 1889-1936: Hubris, there is also a photo of a 12-year-old Hitler with his class at Leonding school, standing in the center of the back row, with his arms crossed, a rather haughty look on his face, almost looking like the future dictator he was to become. As a young man, he witnessed the painful death of his mother from breast cancer and was very fond of the opera, spending nearly all his spare money on tickets to see Wagner. He dreamt of being an artist and was even a bit of a dandy. When he failed to gain entrance to art school and his money ran out, he lived in a men's shelter and barely got by selling postcards of paintings of famous Viennese landmarks. It may have been at that time that the seeds of his later radicalism were sown, as there were a number of anti-Semitic agitators, particularly Karl Leuger, whom Hitler greatly admired. Hitler later served as a courier (a dangerous job) in World War I, by most accounts admirably. It was only after the war that he became involved in radical right wing politics and eventually the Nazi Party, as many did in the wake of Germany's defeat and the myth of the "stab in the back" that lead to defeat.

Oh, yes, Hitler was human. He, along with other great scourges of the 20th century, such as Stalin or Pol Pot or any other monstrous dictator, demonstrate the depth of the human capacity for evil. As Oliver Hirschbiegel, the filmmaker responsible for Downfall, said:
There have been a few voices worried about depicting Adolf Hitler as a human being. But it is ridiculous to regard the Nazis as sent by the devil. There is evil in all of us.
Indeed there is. And, like him, I ask:
How was it possible for a whole nation to fall into barbarism, following this absurd vision of the world and turning loving fathers into vicious killing monsters who felt no pity for their victims? As a civilized nation we have to do that, because no matter how painful, we have to be able to look into each other’s eyes right.
Indeed we do, particularly as Adolf Hitler fades into the mists of time and those who were alive to witness his deeds disappear from the earth.

Friday, April 29, 2005

A final word on Teron Francis

Teron Francis, the unfortunate 13-year-old Bronx boy who developed meningitis from a dental abscess and was declared brain dead last week, leading to a legal battle by the family to prevent the hospital from disconnecting him from the ventilator was finally taken off the ventilator yesterday afternoon, after which his body died. Apparently, his body had begun to deteriorate physically (which is what bodies do once the brain dies). Unfortunately, the news coverage still got it wrong, with headlines like "Brain Dead Bronx Teen Dies" (no, he was already dead) and mush-brained quotes like this from the family's lawyer Robert Genis, who was all over the news last night:
It was like watching an execution. You're watching the doctors and nurses disconnect everything, then you are just waiting for him to stop being a human being.
No, it's not anything like an execution. I know from personal experience of having had to do the disconnection that it's very sad and painful for the family and staff, but it's nothing like an execution. It is the acknowledgment of reality, that Teron passed on over a week ago. Tragically, that is when Teron stopped "being a human being," not yesterday. Genis' ill-advised legal intervention and Judge McKeon's bad decision only prolonged the agony of the family and served to muddy New York case law with regard to brain death. It would not surprise me in the least if several more similar legal actions ensue.

Thanks to Vanessa for pointing out the above quote to me.

Get me a barf bag!

Frank Peretti, writer of Christian novels, has decided to take on evolution in a horror novel he has written, entitled Monster. Quoth he in an interview he gave while promoting his book in Alabama:
My goal is to make them think about evolution. Evolution as a philosophy makes monsters out of all us. It removes all that makes us human - morals, virtue, love, honor, self-sacrifice. All those become illusory. I'm trying to raise some questions. Who is the real monster here? I do it through a monster story.
"Evolution as a philosophy"? What the hell is he referring to? My best guess is that he's confusing social Darwinism and eugenics with biological evolutionary theory, but who knows?

Even worse, look at what he says in this interview:
There are two themes that are in the book that come through strongest. Evolution walks on two legs. One is beneficial mutation, purely random, and the other is natural selection. The whole idea is that some organism, purely by accident, has a mutation in his genetic structure and purely by accident that becomes beneficial because it helps him survive better. So he survives better than all of his other compatriots that don’t have that mutation. Then over billions of years, and billions of mutations, you end up with every living thing on the planet.

Well, I am presenting a thesis in this book that there is no such thing as beneficial mutation. And in weaving this whole story together, that’s what propels the story because this particular scientist decides he is going to prove that beneficial mutations really work. So he starts messing around with the DNA of some animals trying to prove how evolution works. And of course, as in most of these pretty cool monster stories, it is the old pattern of this scientist is messing around with things that are best left. You’ve seen that in all the great horror movies.

So one thing I want to do in the book is just get people to ask questions, to say, ‘Wait a minute, do mutations really work? Is that a really viable pillar for evolution?’ We’ve been told all of our lives that it is purely through mutations that this happens. We’ve even seen it in the movies. Look at X-Men, they were all these mutants with all these special powers. The whole thing was built off the premise of evolution.
When he brought up the X-Men, I knew he had no clue what he was talking about. As for there being "no such thing as a beneficial mutation," obviously he hasn't heard of the CCR5 receptor mutation that makes T-cells far less susceptible to infection with certain strains of HIV than wild-type--and that's just one example. But he's not content to stop here:
I want people to ask questions about evolution, but there is a deeper philosophical theme here too. The logical outcome of evolution is that it makes monsters. We turn into monsters because evolution takes away everything that makes us human in the sense of our moral accountability, our moral absolutes, and our idea of being distinct from the animal kingdom. The prime directive becomes survival. It’s not a matter of what is right or wrong, what is virtuous, what is honest, what does God think, it is all a matter of survival. When that is your prime directive, then virtually anything is possible.

"The logical outcome of evolution is that it makes monsters"? I realize it's only a work of fiction and that bad science is common in horror novels, but such mind-boggling ignorance is hard to fathom. But hang on, it gets even worse. When asked if he wanted to have his book gain crossover success among the general public, here's what Peretti said:
Oh, absolutely, because the secular audience more than anybody is the one that is brainwashed by evolution. They have been told it all their lives. They believe it. If I can get them to ask just one question, I’ll be happy. “You know, I wonder if mutations really do work? I’ve been told that all my life, but I’ve never seen any. They don’t happen on a regular basis; they are not observable in nature now. If we don’t observe them in nature now, how can we know they ever happened in the past?” I’d like to just get them thinking instead of just swallowing all this stuff.

"Brainwashed by evolution"? "I've never seen any [mutations]"? (Well, whoop-de-do! Just because you haven't seen them doesn't mean that scientists haven't.) "They don't happen on a regular basis"? "They are not observable in nature now?" This is creationist drivel of the worst magnitude! I'm not even sure that William Dembski would sink to this level.

Get this man over to Talkorigins.org, STAT! Not that it'll do any good; he's clearly too far gone. But hopefully some of his readers aren't.

As I was getting ready to post this, I just noticed that PZ has already commented on this clown as well, but fortunately for him he wasn't aware of the true--shall we say?--horror of Peretti's additional comments about beneficial mutations.

60 years ago today: The liberation of Dachau

Sixty years ago today, the Third Reich was collapsing. British and American forces were advancing from the West, and had met at the Elbe River four days prior on April 25, cutting German forces in the north off from those in the south. The Soviets had completed their encirclement of Berlin and were well into the final assault, advancing slowly through the outskirts of the ruined city towards the Reichstag itself. From his bunker, surrounded by sycophants (as well as connivers desperate to avoid capture by the Russians), Hitler gave grandiose orders for elaborate counterattacks to armies and divisions that no longer existed, and Berlin's defenders desperately threw untrained and poorly armed 14 year old boys from the Hitler Youth into the fray to take on Soviet tanks, artillery, and Red Army soldiers battle-hardened from years of savage warfare on the Eastern Front.

As Allied forces advanced from both the East and the West, they encountered evidence of Nazi brutality towards their enemies. In January, the Soviets had captured Auschwitz (and here) as they stormed through Poland, but it would be almost three more months before American and British forces started to see firsthand evidence of Nazi atrocities in the name of their war on the the Jews and any enemy of the Reich they perceived. In April, in rapid succession, U.S. and British forces liberated Mittelbau-Dora, Buchenwald, Bergen-Belsen, Flossenbürg, and other camps.

60 years ago today, the U. S. Seventh Army entered Dachau.

Dachau was the oldest of Nazi concentration camps. It was officially opened for business on March 22, 1933, a mere seven weeks after Hitler had become Chancellor on January 30, 1933. Its opening was preceded by notices in major newspapers that enemies of the new regime could end up there. By May, there were well over 1,000 prisoners in the camp; by the end of 1933, over 4,800. In June 1933, Theodor Eicke was appointed commandant of Dachau and over time developed organizational methods and plans that later became the template for future concentration camps. But Dachau was the prototype, the "granddaddy" of all Nazi camps. Indeed, it later became a major training site for SS concentration camp guards. In the early days of Dachau, those imprisoned there were mostly political prisoners, including political opponents of the regime, Communists, Social Democrats, trade unionists, and occasionally members of conservative and liberal political parties who spoke out too vigorously against the Nazi regime. The first Jewish prisoners were also sent to the Dachau concentration camp because of their political opposition. In the following years new groups were sent to Dachau, including more Jews, homosexuals, gypsies, Jehovah's Witness, and Catholic priests who would not accommodate themselves to the Nazi line to the satisfaction of the regime. In the wake of Kristallnacht, more than 10,000 Jews were sent to the Dachau concentration camp. Once war broke out, Dachau became a prisoner of war camp, as well. Over time, German prisoners, once the vast majority of inmates at Dachau, were outnumbered by Poles, Russians, and various other types of prisoners. From 1933 to 1945, over 200,000 prisoners from over 30 nations were imprisoned at Dachau, with a total death toll of at least 30,000. However, this is almost certainly an underestimation of the true death number, given the large numbers of Soviet prisoners who were summarily executed there in 1941. Deaths in Dachau resulted from starvation, disease, overwork, shooting, hanging, lethal injection, and (although there has been controversy over whether the gas chamber at Dachau was ever used in the manner of the one at Auschwitz or other death camps, or how often) occasionally by gassing.

And, like the case at Buchenwald, there were also twisted medical experiments, mainly conducted by Dr. Sigmund Rascher, including low temperature experiments, in which prisoners were immersed in freezing water to determine how long humans could survive in frigid water and high altitude experiments in which patients were subjected to low atmospheric pressure until they died. Another set of experiments were conducted in which prisoners were given only salt water, with the goal of determining how long they could survive.

On the morning of April 29, 1945, U. S. forces entered Dachau. In the weeks prior to the arrival of U. S. troops, the Germans had been transporting concentration camp prisoners out of camps close to the front to camps in Germany proper, and thousands of prisoners had arrived at Dachau, emaciated, ill, and dying, to be added to the thousands of similarly ill prisoners remaining at Dachau and its subcamps, and at the time U. S. forces arrived there were approximately 30,000 prisoners remaining. Indeed, according to some accounts (and here), the horror that greeted U. S. forces at Dachau was even worse than that at Buchenwald or Bergen-Belsen, as hard as it is to believe. The stench of death was everywhere, and scenes like this greeted American soldiers as they explored the camp. Most of the guards had fled, but a few remained, and, unfortunately, although accounts of the circumstances surrounding the incident vary, between 20-30 SS guards were reportedly gunned down by American troops after surrender, so disgusted were the American forces that entered the camp, while a few were killed by former prisoners. One particularly horrific find was a string of over thirty railway cars filled to capacity with the emaciated corpses of men, women, and children, many in advanced states of decomposition. So debilitated were the remaining prisoners that, despite the best efforts of American forces to help them, over the two months following the liberation of Dachau, 2,400 inmates died of starvation and disease. However, given the desperate conditions that greeted American forces, it is actually probably amazing that more didn't die. (An interesting account of the administrative and logistical nightmare that the Americans in charge of post-liberation Dachau had to deal with can be found in this Masters thesis.)

A few firsthand accounts of the horror and chaos that greeted American liberators follow.

Brigadier General Felix L. Sparks, AUS (Ret.):
The scene near the entrance to the confinement area numbed my senses. Dante's Inferno seemed pale compared to the real hell of Dachau. A row of small cement structures near the prison entrance contained a coal-fired crematorium, a gas chamber, and rooms piled high with naked and emaciated human corpses. As I turned to look over the prison yard with unbelieving eyes, I saw a large number of dead inmates lying where they had fallen in the last few hours or days before our arrival. Since all the many bodies were in various stages of decomposition, the stench of death was overpowering.

During the early period of our entry into the camp, a number of Company I men, all battle hardened veterans became extremely distraught. Some cried, while others raged. Some thirty minutes passed before I could restore order and discipline. During that time, the over thirty thousand camp prisoners still alive began to grasp the significance of the events taking place. They streamed from their crowded barracks by the hundreds and were soon pressing at the confining barbed wire fence. They began to shout in unison, which soon became a chilling roar. At the same time, several bodies were being tossed about and torn apart by hundreds of hands. I was told later that those being killed at that time were "informers." After about ten minutes of screaming and shouting, the prisoners quieted down. At that point, a man came forward at the gate and identified himself as an American soldier. We immediately let him out. He turned out to be Major Rene Guiraud of our OSS, He informed me that he had been captured earlier while on an intelligence mission and sentenced to death, but the sentence was never carried out. I sent him back to regimental headquarters.

Within about an hour of our entry, events were under control. Guard posts were set up, and communications were established with the inmates. We informed them that we could not release them immediately but that food and medical assistance would arrive soon. The dead, numbering about nine thousand, were later buried with the forced assistance of the good citizens of the city of Dachau.

1st Lt. William Cowling:
A man lay dead just in front of the gate. A bullet through his head. One of the Germans we had taken lifted him out of the way and we dismounted and went through the gate into a large cement square about 800 squares surrounded by low black barracks and the whole works enclosed by barbed wire. When we entered the gate not a soul was in sight. Then suddenly people (few could call them that) came from all directions. They were dirty, starved skeletons with torn tattered clothes and they screamed and hollered and cried. They ran up and grabbed us. Myself and the newspaper people and kissed our hands, our feet and all of them tried to touch us. They grabbed us and tossed us into the air screaming at the top of their lungs. I finally managed to pull myself free and get to the gate and shut it so they could not get out. Then I felt something brush my shoulder and I turned to the left of the two block house guarding the gate to find a white flag fluttering square in my face and on the end of it inside the house eight Germans.

I looked around the house and entered. I got the same question, are you an American Officer and said Yes. They turned over their arms, pistols and rifles to me and I told them to sit tight. I then went back outside and sent my driver to get the Jeep. Then I went back into the Germans and took their arms and sent the pistols to my Jeep (I gave all away but two). When I came back out the General was there and the people inside the enclosure were all in the large square shouting and crying. Then a terrible thing happened. Some of them in their frenzy charged the barbed wire fence to get out and embrace us and touch us. Immediately they were killed by an electric charge running through the fence. I personally saw three die that way. Our troops arrived about that time and took the rest of the guards, Germans (who during all this time had remained in the towers around the prison.) A number of them and I sincerely regret that I took the eight prisoners that I did after a trip through Camp which I shall describe in a minute.

Well the General attempted to get the thing organized and an American Major who had been held in the Camp since September came out and we set him up as head of the prisoners. He soon picked me to quiet the prisoners downs and explain to them that they must stay in the Camp until we could get them deloused, and proper food and medical care. Several newspaper people arrived about that time and wanted to go through the Camp so we took them through with a guide furnished by the prisoners. The first thing we came to were piles and piles of clothing, shoes, pants, shirts, coats, etc. Then we went into a room with a table with flowers on it and some soap and towels. Another door with the word showers lead off of this and upon going through this room it appeared to be a shower room but instead of water, gas came out and in two minutes the people were dead. Next we went next door to four large ovens where they cremated the dead. Then we were taken to piles of dead. There were from two to fifty people in a pile all naked, starved and dead. There must have been about 1,000 dead in all.

1st Lt. Chuck Ferree, USAAF (For personal reasons, I conclude with this account, noting that Chuck died in 1999. I had carried on an e-mail correspondence with him for several months before his death and knew him as an ally on alt.revisionism, where he was a staunch fighter of Holocaust denial. He brought to the table his firsthand accounts of the horrors that Holocaust deniers were trying to minimize. Sadly, I never got to meet him in person.):
Leaving the gas chamber we found further proof of the Nazi claim to everlasting infamy---human bodies heaped hodge-podge filling two rooms and sprawling out the doors. It was here that the cold weather worked to the advantage of the witnesses. The stench of the bodies and the accompanying filth would have been unbearable under other conditions. The odor permeated right through my heavy leather jacket.

Between these crowded morgues was the creamatorium where four yawning doors stood open and eagerly consumed more victims. Outside there was much evidence of bones and ash where the furnaces had been emptied many times of their gruesome contents. Beyond this scene was a stall which had been used as an execution chamber where many had met death by the firing squad.

This death farm was separated from the main stockades by a high wire fence and a moat. Swarming along the fence were hundreds of the more fortunate prisoners who were now liberated and expressing their gratitude.

Beneath the murky waters of the moat were the features of several SS guards and on the opposite bank was a fitting monument to the depth of the Nazi culture. Frozen on the ground were the bodies of several SS troopers who had been slain by their liberated captives before they could surrender to the Americans. At the bottom of each of the many high watch towers, more bodies lay. SS guards who had tried to put up a fight and were killed by the Infantrymen of the 45th. Division. After seeing many more horrors of Dachau it was small wonder that the only superman who still held his head up high was the larger-than-life-sized statue of the SS trooper on the wall.

After 3-4 days touring Dachau, the SHAEF officer and the others in our group flew back to Frankfurt. My passenger commented to me as we settled into our seats: "Jesus Christ, I wonder how many more of these fucking places we're going to find."
Unfortunately, there still remained a few more such "fucking places" to be discovered, but, even if not another concentration camp had been found, Auschwitz, Buchenwald, Bergen-Belsen, and Dachau alone were far more than enough to show the depths of depravity to which humans could sink. Fortunately, the author of this horror had only one more day to live, and the totalitarian nation he had created only slightly more than a week.

Thursday, April 28, 2005

Debunking cancer myths

Here's a nice article debunking a number of cancer myths. It's good to see the mainstream press occasionally publishing such interviews, rather than the usual glowing puff pieces they all too often like to publish about various alternative medicine "cures."

It makes some nice additional reading to check out after this week's Skeptics' Circle!

(Thanks to St. Nate for pointing this one out.)

Another Skeptics' Circle is here

The Seventh Skeptics' Circle has been posted at Thoughts from Kansas. Once again, we admirers of the Amazing Randi have tried our hand at reinforcing the master's work and inoculating the blogosphere against all forms of credulity and magical thinking. Check it out!

And, two weeks hence, PZ at Pharyngula will host the Eighth Skeptics' Circle. So, skeptical bloggers, start writing, so that you can strut your best skeptical stuff. Maybe if I'm lucky another apparition of the Virgin Mary will appear to give me ideas for my contribution!

A sad end to a sad tale

[A NOTE BEFORE STARTING: In the media accounts cited, I've seen the name of the unfortunate boy in this case spelled both "Teron Francis" and "Taran Francis." I do not know which spelling is correct.]

I've been commenting (also see the update) on the Taran Francis case this week a bit more than I had planned (in fact, it's kind of muscled out the other science-related posts I had been planning, but that's OK). Today, the sad case will finally come to an end, and I hope that the family will finally be able to find some peace. To recap briefly, Taran Francis is a 13-year-old boy who went into a coma from an untreated abscessed tooth and developed meningitis, which ultimately progressed to brain death. When informed of this diagnosis, the family got a lawyer and won a ruling that prevented the hospital from removing life support.

My initial take on the matter was that this was a horrible ruling, both bad law and bad medicine, because it distinguishes between brain death and death and, worse, forces the hospital, in effect, to keep a corpse alive indefinitely as long as the family wants. I speculated that the family would eventually realize the futility of this course of action and that they were only prolonging the agony of everyone involved who loved Taran. Thankfully, my speculation turned out to be correct. Even more thankfully, the family came to this realization sooner, rather than later. The family is scheduled to appear in front of Judge McKeon (the same judge who issued the injunction that prevented the hospital from disconnecting the ventilator), where they will ask him to remove the injunction. Later today, the ventilator will be turned off. What happened? The family brought in an outside doctor, who confirmed the diagnosis of brain death, but--more importantly--explained the significance of the diagnosis (that Taran is dead) in a way in which the family could understand and accept. According to this account:
The last minutes of 13-year-old Taran Francis's life will be today. He's been brain dead for a week now, an agonizing week in which his family fought to keep him on a respirator. But last night, an independent doctor examined Taran and changed their mind.

Robert Genis, the family's lawyer: "He was polite, he was respectful of her. He spoke to you the way you'd want a doctor to speak to you and when he explained to her, her child condition she understood"
I had always suspected that this conflict was due to a problem with communication more than medicine. They almost always are. These are among the most difficult situations to deal with and explain to a patient's family, particularly when that patient is a child. One particular mistake I perceive was that last week someone from the hospital apparently mentioned that state law permitted the hospital to remove Taran from the ventilator 24 hours after the diagnosis of brain death. Whether it was intended that way or not, it was clearly perceived by the family as a threat to remove the ventilator in 24 hours. Even worse, if the family account is correct, they were told that the only reason the hospital was keeping Taran alive was in case they wanted to donate his organs. It's usually not the attending doctor who points this out to the family, in my experience, but rather residents (who are much less experienced in these delicate matters) or other ancillary staff, sometimes even in passing. Also, the rhetoric coming from the hospital on the news media didn't help. Although the frequent statements in the media that Taran is "dead" and "has been dead for a week" were without doubt 100% medically correct, they were delivered in manner that came across as rather harsh on TV and the radio, even to me, someone who is inclined to be sympathetic to the hospital's point of view and the problems inherent in dealing with such delicate situations. Such statements probably contributed to a "circle-the-wagon" mentality in the family, confirming in their minds their worst suspicions about the hospital.

However, it might not have been entirely the hospital's fault. Clearly Taran's family is very religious (the frequent quotes by them in the media "hoping for a miracle" and the frequent references to prayer). Although Catholicism, most sects of Protestantism, and many other religions accept that brain death is death, there are fundamentalist Christian sects, Buddhists, orthodox Jews, Buddhists, and a variety of other religions that do not accept brain death as "real" death, insisting that death doesn't occur until the heart stops beating. Also, in poor communities, particularly African-American communities, it is not uncommon for there to be prevalant an extreme mistrust of doctors and medicine (a distrust that I've experienced myself in dealings with patients). This distrust, often exaggerated even when justified, makes it all too easy for quacks to prey on poor people in these communities, and I'm guessing that it was one factor that made it easy for the family to be convinced that the doctors have no interest in Taran, other than as a source for organs. (Never mind that in this particular case it is highly unlikely that this is true, given that Taran's systemic infection probably ruled him out as an organ donor.) Mix fundamentalist religious beliefs and unrealistic hopes for a miracle with a pre-existing distrust of doctors and hospitals, and even a perfect handling of the delivery of the bad news to the family might not have prevented this conflict. However, letting the family get the message that the hospital was threatening to turn off the ventilator and was interested only in Taran's organs was disastrous. It reinforced the preexisting mistrust, amplified by questions about whether Taran's dental abscess was handled appropriately that probably led the family to be suspicious that the hospital had screwed up.

Fortunately, the outside doctor was able to overcome these problems. I recall hearing on the radio a statement from the family's lawyer along the lines that, if only the original doctors had discussed Taran's situation with the family in the first place in the manner that this outside doctor did yesterday, then the family probably would never have opted for legal intervention last week. (Of course, I still think he should have told the family that they have no case, but people will accuse me of lawyer-bashing when I say that.)

I will remember this case (and, hopefully learn from it) as an example of what can happen if communication breaks down between doctor and patient or patient's family. It has often been said that behind most malpractice suits is bad communication between the doctor and patient, regardless of whether malpractice actually occurred. It's equally true that communication failures can result in other kinds of ugliness, like the legal battle over the Taran Francis case. Fortunately, intervention with better communication kept this case, and the agony of Taran's family, from dragging on too long.

Wednesday, April 27, 2005

A field guide to biomedical meeting creatures, part 2: Poster time!

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Since I've started blogging, I notice things that I probably wouldn't have noticed before. I suspect it's because blogs are a voracious sink for writing and require feeding with a regular infusion of new ideas. Fortunately, the AACR Meeting provided a veritable cornucopia of ideas, and I even had the foresight to jot many of them down.

So it was at the session at which I was presenting a poster.

For those who don't know how poster sessions are run at such meetings, I'll give a little primer. First, you must understand the hierarchy of presentations at these meetings. The best abstracts get chosen for plenary session talks (like the one I was fortunate enough to be chosen to give last month, which partially inspired me to write this). Plenary sessions are often the only session going on at the time they occur, but even if other stuff is going on they are always the biggest sessions. The second best abstracts are chosen for smaller talks in smaller, parallel sessions. The third best are chosen to present posters. The fourth best are deposited in the circular file after a rejection letter is sent to the authors. Oh, there are variations, depending upon the size of the meeting. Because AACR is so big, there are in essence three different levels of parallel sessions called Symposia (bigger guns--but not Plenary Session big guns--giving talks), Mini-Symposia (usually graduate students, fellows, and junior faculty), and Poster Discussion sessions (basically a poster session in which the presenters are allowed to give a five minute talk). But they all break down into specific levels of prominence, a veritable pecking order, if you will.

My abstract happened to be chosen only for a poster session. (Ah, well, win a few, lose a few, I guess, given that I was just one notch above rejection.) Unlike some other meetings, that's not so bad a thing at AACR, for the simple reason that, at the AACR Meeting, it's quite rare for any but the heaviest of heavy hitters to be invited to give plenary talks. Heck, this year even Judah Folkman (my angiogenesis hero, whose work I'll write about sometime in the near future) and Max Wicha (I plan on writing about his work on breast cancer stem cells in a future post, along with a bit about of my skepticism about the concept) were giving talks at Symposia, rather than Plenary Sessions (although the organizers badly miscalculated how many people would want to see Max Wicha, even at 8 AM, leaving those of us who didn't get there 10 minutes early either standing along the walls or sitting on the floors straining to see the slides, much to the annoyance of many).

Poster sessions come in many shapes and sizes. At the core of all of them is the presentation of your data in a concise (an hopefully attractive) form on a poster, and during the session the presenters are expected to hang out by their posters for some period of time, in case attendees want to ask questions. At their best, poster sessions are a chance to schmooze with more prominent scientists, many of whom actually like to wander around and check out various posters. At their worst, they are a chance to stand or sit forlornly by your poster as sparse attendees wander by, briefly glancing blankly at it. In that aspect, they are not at all unlike high school dances. (Indeed, I've decided that I will never present a poster at one meeting in particular again because the sessions were so poorly attended and there was so little interest in anything of a basic science nature, like much of my work.) The AACR is amazing in that the poster sessions are absolutely enormous (just check out the pictures I posted along with this piece), and there are seven of them, each lasting four hours, one in the morning and one in the afternoon of every day of the conference except the last. There are easily several hundred posters per session in the biggest hall in the convention center, for a total of over 5,000 posters presented over the course of the meeting. Presenters are expected to stand by their posters for the first three hours of the session, which can get really boring really fast if you don't have a lot of traffic by your poster.

One of the potentially biggest bummers about taking part in a poster session occurs if you happen to be unlucky enough to be stationed next to a high traffic poster. I've had this happen to me a couple of times at AACR. You stand there, with no one looking at your poster, while an overflow crowd of 20+ people is milling around the poster next to you, bumping into you, giving you annoyed looks because you have the audacity to stand next to your own poster, blocking the spot that they wanted to use to look at the poster next to you! Fortunately, that didn't happen to me this year, but unfortunately the traffic by my poster was only moderate. It probably didn't help that I happened to have drawn a spot just north and east of Siberia, as far as the convention floor goes.

Like the types of questioners at scientific talks, there are different styles of poster presenters, which you will come to recognize rather quickly if you ever get the opportunity to present a poster. They include (but, of course, are not limited to):
  1. The Schmoozer. This guy (or gal) wants nothing more than to make as many contacts as possible and will do whatever it takes to achieve that aim. If you show the least bit of interest in his or her poster, the Schmoozer will sidle up to you and try to chat you up. (Characteristic quote: "Can I have your card? Here, please take mine.") Of course, once the schmoozer finds out that you're merely junior faculty or a fellow, his or her reaction to you will be similar to what you would experience if you showed up with skin lesions characteristic of the bubonic plague or, if you're a guy, the reaction you got the last time you tried to hit on that gorgeous model-quality beautiful chick at a bar. How do I know this one, you ask? Don't ask.
  2. The Ghost. This presenter doesn't like the whole poster thing. The Ghost will disappear shortly after the poster is put up and will be nowhere to be found at any point, until the end, when the poster has to come down. (Sometimes the Ghost will not even show up then and will let the cleaning staff throw the poster away.) Too bad for the Ghost if a heavy hitter or a department head looking for faculty happens to wander by and likes the ghost's poster. The Ghost will have just blown his or her chance at that job at Harvard or M.D. Anderson Cancer Center that he or she craves.
  3. The Carnival Barker. Perhaps the most annoying presenter of all, even more so than the schmoozer, the Carnival Barker will stand in front of his or her poster, beckoning people to "come on in" and check out the poster. Worse, you're not safe even if you're in the middle (or even on the other side) of the aisle, because the Carnival Barker will come out and get you. His or her behavior is not unlike that of a carnival barker or of the people strip clubs in the French Quarter in New Orleans hire to try to get people to "come on in." How do I know about that, you ask? Don't. (A less racy example comes to mind. If you've ever been to Mulberry Street in Little Italy in New York, you know that there are so many restaurants in such a small area there that the restaurants have people who stand in the streets and try to lure passers-by in.)
  4. Impervious. Impervious doesn't like the poster thing any more than Ghost, but feels obligated to follow instructions and stay by the poster until the bitter end. That doesn't mean impervious has to talk to anyone or acknowledge anyone's existence. Impervious may be pissed off that his abstract didn't get accepted for a talk or may believe that sitting by a poster is below him. Whatever the reason, the key characteristic of Impervious is his ability to study closely the meeting program, never making eye contact with anyone who looks at his poster, and/or to carry on multi-hour-long conversations on the cell phone while sitting by his poster. (Impervious sometimes even brings along an extra charged cell phone battery, just for this purpose.)
  5. The Pointer. This presenter comes complete with a pointer (either the old-fashioned kind or a laser pointer). And he knows how to use it--much to the annoyance of anyone who happens by his poster.
  6. The Poser. The Poser will be dressed to the hilt (a very stylish suit if a man or a very attractive dress--with just a tasteful bit of cleavage showing or a hemline that's just slightly shorter than one might consider appropriate--if a woman) and will look as though he or she is literally striking a pose by the poster. It almost makes you want to get out a camera. snapping pictures, and start yelling, "Oh, yeah! The camera loves you, baby!"
  7. Lost Little Boy (or Girl). This is the saddest poster presenter of all. Lost happens to have a poster that not very many people are interested in. Consequently, during the time no one is looking at the poster, Lost will sit around and look, well...lost. When the rare meeting attendee shows the slightest bit of interest in Lost's poster, he or she will focus a gaze on the attendee not unlike that of a puppy who wants to go out and play. How do I know about this one, you ask? Don't. Really. Don't.
Of course, the people wandering by and checking out the posters are an equally eclectic bunch. There is considerably overlap between these people and the people I previously describedwho come up to ask questions after a scientific talk. Indeed, you can encounter almost any of them, with the exception of the Moderator, because there is no Moderator. It's also unusual to encounter Pontificator, Show-off, or Me-Too. (Mainly because there is no real audience for them to try to impress, so what's the point?) However, in the poster session, there's a huge difference inherent in it because of its structure. In the poster session setting, certain of these creatures can be much more of a threat that they normally are at any scientific talk you might give, because there is in essence unlimited time for them to torment you and no way for you to escape. There's no Moderator to keep Conniver or Rival from pumping you for as much information as he can about how far along you are compared to him; to keep Clueless Wonder from wasting huge swaths of your time with idiotic questions; or to keep Nonsequitur from asking interesting but largely irrelevant questions. But worst of all, there is no time limit and no escape from Oh Shit!, who can spend as much time as he or she wishes tearing at the flaw he or she's discovered in your work and convincing you what a careless scientist you are. It is a true poster warrior indeed who can disarm these fierce foes, who are but annoyances in most scientific talks but can be determined destroyers of your sanity in the very different setting of a poster session. Your only hope (and only escape) is for your poster to be so popular that you can quite correctly tell any of them that you have to be fair to the others there and talk to them too. If your poster is not sufficiently popular and you're stuck one-on-one with any of them, you're royally screwed.

There are, however, a few questioners who are more or less unique to poster sessions. They include:
  1. Don't Talk to Me (a.k.a. "I Vant to Be Left Alone"). This variety of poster browser is the counterpart of Impervious. He will stand in front of your poster for many minutes, apparently drinking in every word of your brilliant prose and studying every figure with great interest, sometimes even making little "uh-huh" noises, but will ignore you completely. If you try to ask him if he has any questions, it's no different that talking to a rock.
  2. James Bond. Usually affiliated with a pharmaceutical or biotech company, James Bond walks around with his digital camera and takes pictures of the posters, sometimes blatantly, but sometimes in a rather furtive manner. Of course, he could be afraid of getting caught, given that the rules against photography or audio recording of posters and talks are posted everywhere, but they are rules that don't ever seem to be enforced, in my experience. Sadly, the stereotype is not entirely incorrect here, as most James Bonds I've seen are Asian.
  3. The Clueless Wonder. OK, he's not unique to posters, but no one (and I mean no one) can waste more of your time or make your poster presentation experience more miserable than a clueless wonder cornering you. Pray that he doesn't find your poster early in the poster session.
  4. Tell Me All About It. Perhaps the most annoying (and unfortunately probably the most common) of the unique poster warriors, Tell me's characteristic opening line is, "Please, take me through your poster," or "Please, tell me the story." It's not as if you didn't spend hour upon hour carefully crafting your figures and text and arranging them carefully on a poster to, oh, tell your story in a succinct and interesting (and hopefully visually attractive) way, but this clown wants it all spoon-fed to him or her! After about the tenth time leading someone through my poster, I've been know to swear that the next person who comes up to me and asks me to "tell me all about it" will die a horrible, slow, painful death. Unfortunately, I don't have the courage of my convictions, and they never do. I suppose that it helps to remember that they are actually showing an interest in your work, even if they're too lazy to actually read your poster.
And there you have it, the poster warriors. As you can see, as is the case for giving scientific talks, there is more to presenting a poster than just standing there. However, forewarned is forearmed, as they say, and if you know what kinds of curveballs might be thrown your way, you have a much better chance of hitting them out of the park (or at least not striking out). You might even have fun.

Unless you happen to be Lost Little Boy (or Girl).

I wonder how many of my colleagues will recognize these creatures and whether they can suggest more. The floor is once again open!

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I'm not worthy, I'm not worthy!

I was going over my Sitemeter logs last night when I noticed a bunch of referrals from Majikthise and Kung Fu Monkey (whose tagline, "Because your monkey's Kung Fu is not strong," I happen to really like and whose post I Miss Republicans I mentioned a while back as being right in line with how I became disillusioned with today's Republican Party). It looks like both have plugged humble Orac, Kung Fu Monkey in his new links (although I'm not sure I'm as much of a "smart guy" as he says) and Majikthise in reference to my posts on the Taran Francis case. Where I dwelt on the medical and patient care issues of the case, specifically the medical and legal implications of brain death and how ill-advised I thought the legal action taken by the family was (even though I realized how devastated the family must be), Majikthise focused on a different aspect, wondering whether the hospital would have treated Taran's family better if he hadn't been poor. (It's an aspect I didn't address specifically, mainly because, having been involved in a few cases like this as a resident on the trauma service, I know that it can be hard to figure out whether the hospital was truly that insensitive or whether the family is in denial because of the tragedy. But she does make a good point, if the account in the New York Post of how the hospital delivered the information to the family is accurate.)

Anyway, thanks to both, and I like your blogs, too.

I'm not worthy! I'm not worthy!

Tuesday, April 26, 2005

Damn! How could I have missed this?

Apparently yesterday was DNA Day. It marks the 52nd anniversary of Watson and Crick's description of the DNA double-helix, and the national day has been officially recognized since 4/25/03.

How on earth could I have not known about this?

Oh, well, happy belated DNA Day.

Grand Rounds XXXI

Grand Rounds XXXI has been posted at Dr. Tony's blog. Once again, the best of the medical blogosphere has been condensed into one succinct package, and once again you should check it out forthwith! (But don't forget to come back here when you're done...)

Another Skeptics' Circle is nearly upon us!

The Seventh Skeptics' Circle is scheduled to be posted at Thoughts from Kansas on Thursday, April 28. I submitted my entry yesterday. Have you?

If not and you're a blogger, then send your best skeptical blogging to Josh by Wednesday night. Instructions are here. As Josh puts it:

If you're lucky, the Amazing Randi might even read your stuff!

I know he's read my stuff at least once. (I'm hoping to get him to read my stuff again someday.) Maybe he'll even offer to help me get it published in Skeptic. (Hint, hint.)

Nahh, that's probably too much to hope for.

Update on the Taran Francis case

Yesterday, I discussed the very sad case of Taran Francis, the 13-year-old boy who suffered meningitis from an untreated dental abscess that progressed to meningitis and brain death and the motion filed by the family's lawyer to prevent life support from being removed. (I've also seen it spelled "Teron Francis" and am not sure which spelling is correct.)

Although the thought of what the family is going through is heart-rending, my first take on the issue was that the legal action was ill-advised, because brain dead is dead. Keeping the boy's body alive when his brain is dead is a very expensive exercise in utter futility. Also, my guess was that this was probably a matter of poor communication between hospital personnel and the family. My second take (in the Addendum I posted) confirmed this impression, when I found out more information in an account that revealed that hospital officials might have been insensitive in dealing with the family, telling them that they would only have 24 hours to come to terms with Taran's death and implying that the only reason they were keeping Taran's body alive is because the family might want to donate his organs. Whether that is how the hospital actually presented the situation to the family or not is impossible to say from the news reports. Having had a little experience with such situations during the trauma rotations I took during my residency, I know that, on occasion, no matter how sensitive the hospital staff is in relaying the tragic news, the family still doesn't hear. (On the other hand, the story that the family relayed of a member of the staff telling them that the only reason they were keeping Taran's body alive was in case they wanted to donate his organs rings truer than I would like to admit.) Given that additional information, however, I could understand why, if the family had gotten the impression that the hospital was eager to pull the plug (whether correctly or mistakenly), they might have felt compelled to sue, even though I still think the legal action was very misguided and ultimately self-defeating.

Now, I've found out that the Judge Douglass McKeon ruled (and here and here) today that the boy could not be taken off life support without his family's permission. This is a bad ruling. It's bad because it in essence invalidates the law in this particular case, and it's bad medicine. No, I am not saying that the hospital should pull the plug right away, given that they had already come to an agreement not to before the ruling. It is highly unlikely that, in the face of the negative publicity it has received, the hospital would do so anyway. The ruling is also bad medicine, in that it leaves the impression that brain death is not the same thing as death, when such is not the case. Given the timidity of the ruling, I have to wonder if Judge McKeon was afraid of a Terry Schiavo-like controversy, were he to reverse his restraining order. Even worse, he doesn't seem entirely objective, given that he brought his wife to Taran's bedside, where she prayed for him.

But, as I said before, this case is not the same as the Terry Schiavo case. Terry Schiavo was in a persistent vegetative state; she was not brain dead. Terry Schiavo could have lived indefinitely in her persistent vegetative state if her feeding tube had been maintained; without the brain, Taran's body will deteriorate and die regardless of what anyone does. Maintaining his shell "until his heart stops" (as his mother put it) does Taran no good, nor does it do the family any good, prolonging as it does the agony of the family's ordeal. Personally, I had a fair amount of ambivalence about whether letting Terry Schiavo die was the right thing to do before I formed my opinion on that case; I have no ambivalence in my conclusion that disconnecting the respirator from Taran would be the right thing to do, assuming the diagnosis of brain death is accurate.

Unfortunately, some of the same groups that rallied to Terry Schiavo's cause have taken on Taran's cause (see also here and here), even though the two cases are not analogous. They do so based on a flawed understanding of the significance of brain death:
Nor should any one have to meet some arbitrary standard of recovery to justify his life. It is sufficient to survive. Finally, if Taran were truly dead, he would have suffered rigor mortis by now. Would they bury a breathing boy with a beating heart in the ground? Then why murder him?
I'm sorry, but sadly Taran has not "survived." He has already passed on. Unfortunately, his shell remains with the appearance of life, but it is not life. It is not "murder" to accept that the boy's brain has died and withdraw artificial means of supporting the remaining shell of a boy from whom life has already fled (and whose body will not survive for long, even on a ventilator). I think that the family will eventually come to this realization, too. I'm just profoundly sorry that an apparent lack of communication between the hospital and the family allowed an already tragic situation to escalate to such depths of ugliness, regardless of whether the misunderstanding was due to the hospital's insensitivity or the family's inability or unwillingness to let go. Going to court over this served no good purpose and muddied the issue of how brain death is dealt with in New York.

Monday, April 25, 2005

A tragic story

I became aware of a very tragic story yesterday. (Other links here, here, and here.)

Last Monday, a 13-year-old Bronx boy named Taran Francis was taken to Bronx-Lebanon Hospital with a severe tooth infection. A day later, he developed meningitis, slipped into a coma, and deteriorated. He was transferred to Montefiore Medical Center, and on Wednesday the family was told by doctors that he was brain dead. (Note: I've also seen the boy's name spelled "Teron Francis" and am not sure which spelling is correct.)

While I can understand how the family would be utterly devastated by the horrible (and possibly unnecessary) death of their boy and that they might be considering a lawsuit, given that the tooth infection had been diagnosed 11 days before and that he had been turned away from getting his root canal two days earlier because he didn't come with a guardian, I think that their grief is leading them to do something very inappropriate. They are suing the hospital to keep their son on life support:
We are holding on to him," said the boy's aunt, AnnMarie Douglas, as family members continued to hold a bedside vigil at the hospital for young Teron Francis.

"We are not giving up. We believe in God. He has life. I don't care what they say.

"Until that heart stops, we're not letting go of him," Douglas said.
At the risk of seeming callous or insensitive (which I am not, I assure you, having had to deal with brain death in children during trauma rotations in my residency days, experiences that haunt me to this day), I also have to view this as a teachable/bloggable moment. If the diagnosis of brain death is accurate and properly determined and documented (see here also), then, sadly, Taran is already dead. His body can be maintained on life-support for a while, but, without the brain its organs will slowly start shutting down, and there is nothing anyone can do about it. This is not the same as a persistent vegetative state, like the Terry Schiavo case, in which there was still brainstem function and Schiavo could still breathe on her own. In brain death, there is no higher brain or brainstem function. Brain death can be diagnosed on strictly clinical grounds, but most of the time it's confirmed by a cerebral blood flow scan, which will show no bloodflow to the brian or brainstem. Keeping the boy on life-support ("holding on" to him) only prolongs the suffering of the family and wastes huge amounts of hospital resources on an utterly futile gesture. Indeed, in most states (including New York) once the diagnosis of brain death is made, then life support can be withdrawn (usually after 24-48 hours to give the family time to gather) regardless of the parents' wishes. That doesn't mean that every effort shouldn't be made to withdraw support in as sensitive a fashion as possible or that there shouldn't be the flexibility to delay it for a while, if necessary, to give the family some time to come to terms with the situation or so that all the family can be there when the machines are turned off. However, unless there is a good reason to question the diagnosis of brain death, keeping a brain-dead boy on life support indefinitely, hoping for a "miracle" is misguided. (Even the family's lawyer is not challenging the diagnosis of brain death, as far as I've been able to ascertain.)

Even worse is that this lawyer would file such an ill-advised motion. Although I rarely agree with hospital flacks, in this case, I reluctantly have to agree with Montefiore's spokesman, who said: "The case and what this lawyer is doing is atrocious and a disservice to this family." Indeed. The family has just endured a horrific tragedy, one that will cause them pain to remember for the rest of their lives. They can be certainly be excused if they are not thinking objectively, are unable to understand brain death, or can't come to terms with the situation yet. They should be dealt with as sensitively and respectfully as possible. The lawyer, as an objective third party, cannot be excused for pursuing court action in a case like this, particularly given that the diagnosis of brain death does not appear to be in dispute.

I can only speculate here, but I rather suspect that the hospital might not have handled delivering the news to the family in a sufficiently sensitive manner, or that the doctors came across to the family as being too anxious to pull the plug and insufficiently willing to give the family some additional time. (My hunch is supported by the family's claim that doctors told them that Taran was brain dead and that state law allowed them to take him off the respirator after 24 hours.) This whole conflict might have been avoided. When I was training, it was always emphasized that, when talking to a family about the brain death of a loved one, one has to emphasize that the patient is dead; that there is no legal distinction between brain death and death; that we can keep the body alive for a while but inevitably, without the brain, it, too, will die; and that, according to virtually all major religions, there is no moral distinction between the brain death and death. Indeed, some say that we shouldn't even use the term "brain dead," but simply say that the patient is "dead." And, above all, one must be careful never to give the impression of being eager to pull the plug. Finally, in appropriate cases, one should also broach the topic of organ donation (probably not appropriate in Taran's case, because he had had a severe systemic infection). It also helps a lot to have a competent social worker around and (if the family is religious) appropriate supportive clergy, to help them come to terms with the tragedy that has just occurred. It's also possible that the hospital did everything correctly, but that this is just a family that can't let go or won't understand. That happens too, sometimes. It is also not unlikely that they are presently suffering through denial, which can sometimes lead families to behave this way, even when the case was handled perfectly.

In any case, although my heart goes out to the family for what they are suffering, I still have to hope that they will shake off their denial, quickly come to realize that it's over, and let Taran go. If there was evidence of malpractice in the care of their boy, then I have no problem with their filing a lawsuit after they have mourned. But holding on to a boy who has already died will not bring them the peace they crave, nor will it let them move on. What's being kept alive on the ventilator is but a shell. Taran is already gone.


ADDENDUM:

I had had a few misgivings about what I had posted, thinking that perhaps I had been too quick to judge. Then I became aware of this. I think I know now exactly why the family was so quick to sue, and you will too if you read this. So, in my unflinching willingness to admit when I might have done better, I present the money quote from the article:
When a doctor appeared, the two women asked, "Should we be worried about anything?" Douglas said.

"The doctor said, 'Yes. He's literally brain dead.' " Soon after, they were approached by a hospital social worker, who told them, "We're going to give you time to mourn. You have 24 hours," said Douglas.

Asked what that meant, the social worker explained, "Legally, in New York state, the hospital has the right to take a person off life support when he's brain dead," Douglas said.

That's when Marcerlyn called a lawyer.

Douglas noted, "We pleaded with the doctors, 'This child needs time, for Christ's sake. Give him time.' "

In a chilling response, she said, the social worker told them that the only reason the hospital was giving Taran medical attention at that point was "to keep his organs functioning in case you want to donate them."
Ugh!

If that's an accurate account of how the hospital broke the news to the family, then this whole incident is a perfect example of how not to tell a family that their child is brain dead. Although I suspect that the hospital personnel were probably somewhat more sensitive than portrayed, that last statement is almost certainly what pushed the family over the edge. Hospital personnel appear to have broken the cardinal rule in these very difficult situations and given the impression that they were eager to pull the plug (exactly what I said not to do above!). Even worse, the hospital seems to have left the family with the impression that doctors were only interested in the child's organs!

None of this changes the essential fact that Taran is dead (assuming the hospital did evaluated his brain function properly), meaning that continuing to keep him on the respirator is completely inappropriate. However, this revelation (which I should have found earlier--mea culpa) puts the family's decision to sue in a much different light.

How not to win friends and influence people

The question caught me by surprise.

While at the AACR Meeting last week, I was having brunch with a friend I used to work with, whom I hadn't seen in a long time. She and her husband had brought along two of their oldest and dearest friends, whom they had known nearly 50 years, as well as another of my former coworkers. We were idly chatting away and eating, when one of the occupational hazards of being a doctor presented itself. Tthe conversation drifted to medical topics. And then it came.

"What do you think of Dr. Gonzalez?"

Ah, hell.

Blindsided again! Why hadn't I seen that one coming? As a doctor, I find that these sorts of questions hit me when I least expect them. I was half-tempted to play dumb and pretend that I didn't know who Dr. Gonzalez is, but decided against that approach. It doesn't work anyway. I knew feigning ignorance would only result in her telling me who Dr. Gonzalez is. Instead, I asked a single question to make sure we were both on the same page and talking about the same Dr. Gonzalez, "Do you mean Dr. Gonzalez in New York City, the one who uses 'detoxification' to treat cancer?"

"Yes, that's him," she replied.

No escape there. For those of you who aren't aware of who he is, Dr. Nicholas Gonzalez is a physician in New York City who claims to be able to treat incurable cancers with a regimen that includes dietary manipulations, "detoxification" with coffee enemas, and the ingestion of pancreatic enzymes. I've discussed him before in the context of a patient who followed his regimen and paid a price and, indeed, who might even have been treated by Dr. Gonzalez himself. His methods are based on a regimen popularized by Max Gerson. Using this regimen, he claims that he can produce long-term survival in inoperable pancreatic cancer, for which the median survival is usually less than six months. Never mind that his study only had 11 patients who could complete the regimen, had no control group, and, given the rigor of the regimen required, had the potential for serious selection bias (Gonzalez's regimen can sometimes require as many as 150 pills per day). Based on this tiny uncontrolled study, somehow NCCAM saw fit to fund a $1.4 million clinical trial. As I've said before, if I were to submit a grant proposal to the NIH with so little preliminary data, the study section would have a good laugh at my expense before filing my application in the cylindrical file. In fairness, I will give Dr. Gonzalez a modicum of credit for, unlike alties, at least making an attempt to use science to look at his therapy, however dubious the supporting data. Most alties don't make even the pretense of doing that.

I wasn't in the mood. I had just wanted to hang out with some old friends and talk about science, old times, and other topics. Also, I knew that a debunking session would probably not be appreciated (they seldom are, particularly in what was supposed to be a light social situation), and I didn't want to risk offending my friends by being too strident with their old friend. So I tried to discourage her. "You probably don't want to know what I think," I replied, with what I hoped was a self-deprecating smile and chuckle.

"No, I do," she said.

Damn, she's going to be persistent, I thought. Not in the mood for a confrontation, I became more insistent. "No, I really don't think you do."

"Please." She leaned forward.

"You're probably not going to like it," I gently warned her. (If she didn't know what I was going to say now, I couldn't be responsible.)

"Come on."

OK, I warned you. "He's a quack," I blurted out, wincing inwardly at how it must have sounded. "I see no evidence that his 'therapies' do anything for cancer patients." Did you have to use the q-word? Why couldn't you be more diplomatic? I rebuked myself. You know what you normally do in these cases. You normally say that the treatment is unproven, that there is no evidence that it does anything whatsoever to increase long-term survival in cancer patients, but that you doubt it does any harm. (Even if you don't necessarily believe that inside for this particular therapy.) That's how you defuse the situation, avoid unpleasantness, and even possibly educate the people asking about the questionable therapy. You don't use the q-word! (At least, you don't use the q-word with well-intentioned people who just don't know any better. Hard-core alties, on the other hand, are another matter entirely.)

She was silent for a moment. Silverware clinked, but no one spoke. Everyone, my friend included, was looking at me expectantly.

I began a discussion of why I held the opinion I did about Dr. Gonzalez. I was starting to explain that Gonzalez's methods were based on out-dated, faulty, turn-of-the-century concepts of how cancer developed, how there is no good randomized clinical study that shows his methods do anything for cancer patients, and how the only reason his methods hadn't gone the way of Laetrile was because of aforementioned tiny study, which led to the NCCAM study, when my friend's friend interrupted. "You know, my husband and I know one of Dr. Gonzalez's patients."

"Oh, really," I said. So that was why she was so interested.

"Yes, he had melanoma. His doctors told him he should just go into hospice or go home to die. But he went to Dr. Gonzalez, and he's been fine. That was 12 years ago."

Ah, geez. The dreaded "the doctors sent me home to die" cliché of so many alternative medicine cancer cure testimonials--even worse, the testimonial told second-hand to a friend. You can't effectively fight that one without risking serious unpleasantness, and I didn't want things to get too unpleasant, in deference to my friends. I realized that there was no way I was going to convince these people that Gonzalez was using unproven methods with no evidence of efficacy. They believed he had saved their friend's life when no other doctor could. I also realized that questioning them to see if I could figure out whether their friend really did have metastatic melanoma was probably pointless. I guessed that most likely their friend probably didn't have stage IV melanoma and that surgery probably took care of the disease, as it does for the vast majority of melanoma patients who survive the cancer. But people won't believe that or hear it when you say that. (In my experience, lay people rarely have enough information to let me assess the true severity of their friend's or relative's illness.)

So I did the only thing that was left to me. I explained that a single anecdote does not constitute evidence for general efficacy, using one of my favorite sayings, "The plural of 'anecdote' is not 'data.'" I also explained that spontaneous remissions, although very rare, do occasionally occur for melanoma and that it was impossible to assess whether the Gonzalez treatment really worked or whether conventional surgery had taken care of the melanoma. (Remember, when patients undergo surgery and then decide to opt for alternative medicine for the remainder of their treatment, they almost always attribute their "cure" to the alternative medicine, and not to the surgery.) Finally, I pointed out that my skepticism was rooted in both the lack of evidence that Gonzalez's therapy does any good and the flawed "model" of cancer upon which the Gonzalez therapy is based. I told them that it was being studied in a clinical trial but that I sincerely doubted that it would be shown to have much, if any, benefit. I also explained the concept of selection bias, and how the healthiest patients were the ones who could manage to go through Gonzalez's rather rigorous regimen, which could include as many as 150 pills a day.

"Oh," she said. "You know, I heard of another person that Dr. Gonzalez had turned down because he had had so much chemotherapy and other treatments before."

"That doesn't surprise me and only makes me think selection bias even more," I replied.

Perhaps I had gotten through after all--maybe just a little. It also helped that everyone at the table except them were scientists involved in medical research. I got a little tactical air support from them.

The conversation moved on to other topics. I did see everyone again a couple of more times while in Anaheim, and, to my relief, the topic of Dr. Gonzalez never came up again.

But this encounter reminded me of a few things. First, credulity will hit you when you least expect it. Most people who believe in these things aren't alties. They are regular people who just don't have the background in science and critical thinking to assess claims of "unconventional" practitioners properly. Second, many of these people can be educated, but not by stridency or overly strong attacks on their favored practitioner. That's why I winced when I let it blurt out that I thought Dr. Gonzalez was a quack. That could have turned them off so completely that anything else I said would have been discounted. (Fortunately, it didn't, but it could have.) Finally, if you're a skeptic and a doctor, you have to be prepared at any moment to do your part for evidence-based medicine and against unproven and/or ineffective remedies. And remember, don't resort to bluntness until you've exhausted more diplomatic means of getting your message across--unless you're dealing with an altie, of course.

Sunday, April 24, 2005

Even penguins have to go through security

I guess even penguins could be a hijacking threat. You can never be too careful, you know...

Why intelligent design fails

A nice, brief explanation about why intelligent design is not science and why it shouldn't be taught as such can be found here. In about 5,000 characters, PZ succinctly sums up the shortcomings of intelligent design.

The cult of Apple

Having visited the Apple Store in Manhattan (which is very much like the one on Michigan Avenue in Chicago, which I've also visited), I can sort of understand this assertion that we Mac fanatics can sometimes be a bit cult-like. Indeed, when someone switches from Windows to the Macintosh, as one of the faculty at work did several months ago after a particulary bad outbreak of spyware and viruses on his Windows box, it does almost seem religious. Before, he used to mock my love of the Mac, and we would joust in a friendly way over which OS was superior. Now, he's even more enthusiastic about the Mac than I am. (Ah, the fervor of the newly converted!) In any case, for those of us who wouldn't dream of ever using Windows except under duress (for example, I have a cheap Windows box in my lab only because my real-time PCR machine won't run without it), these massive temples to the Macintosh do produce a sense of belonging that we Mac users seldom find in the "real" world. However, I like to think of our devotion as a force for good in the computing world. Can you imagine how crappy Microsoft Windows would be if it didn't have even the single-digit market share competition of Apple to tweak it, if it were an utter and complete monopoly?

I'm particularly intrigued by Umberto Eco's statement in the article that the Macintosh is Catholic, while Microsoft Windows is Protestant.

I bet we could argue about that one for days...