Sunday, October 24, 2010

ASBH, Day Two

How long it takes me to get to the conference hotel in the morning amazes me. It is not the distance: a short way through the Gaslamp Quarter, and I am there. It is not the time spent on the treadmill up in the Indigo Hotel fitness center, overlooking the early morning mist from the ninth floor. Whatever it is, I get to the Hilton Bayshore just as breakfast is wrapping up, and bury a couple of greasy french toasts and two cups of black coffee before the plenary starts. In a mood of haste and impatience.

The plenary was on creative engagement with persons suffering from Alzheimer's. Not something I had thought about before, but it makes perfect sense. Everyone knows the horror stories of older men and women being plunked down all day in front of television sets, and much worse forms of neglect or abuse. So engaging Alzheimer's patients in theatre, painting, songwriting and dance is in stark contrast with other tendencies in Alzheimer care, including early diagnosis and initiation for medication: with the old in general becoming a rapidly growing target market for the pharmaceutical industry, medicalizing approaches tend to predominate. A strength of the presentation was reference to empirical research indicating positive outcomes in 'non-medical' or cultural approaches, and a highlight was the speaker's call for pharmaceutical companies to devote 1% of their operating budgets to programs enhancing a 'sense of purpose' among Alzheimer's patients. Wishful thinking, but a nice thought.

Highlight of the day: a piece of good old fashioned philosophy. In a session on cognitive enhancement, we had two presentations of surveys conducted on attitudes of various populations towards cognitive enhancement, particularly medications for school performance. They were solid presentations, revealing the predictable, i.e. we are in two minds about using drugs to stimulate our minds. This was followed by a talk like a gust of fresh San Diego sea air: Tom Buller from the University of Alaska started asking some fundamental questions about the very idea of cognitive enhancement. Can we make people smarter with 'smart drugs' anyway? Improved memory and concentration is not equivalent to improved intellect. Even if drugs (somehow) improved intellect or knowledge, how valuable is that? Would it make us better people or better societies? Is there such thing possible as moral enhancement through medications? Muller offered skepticism of the best sort: patient, rational questioning of (inflated) claims about what enhancement is supposed to do for us or to us.

A panel discussion about ethics and quality improvement (QI) studies does not sound particularly riveting, but Saturday's session proved otherwise. Quality improvement studies, because they are so closely entangled with ordinary health care delivery, can pose problems for IRBs because it is not always clear whether they fit the definition of 'research' according to the Common Rule. According to the panel members, some IRBs treat QI as health research interventions like any other, requiring at least expedited review, consent forms and all the rest, even when they are very low risk. There was much grumbling about expedited reviews taking too long, and this unleashed a string of negative comments about IRBs, raising the impression of a groundswell of criticism against the Common Rule. There was even talk (gasp) of research institutions opting out of adhering to the Common Rule for all their research activities. However, an official from OHRP in the audience was having none of it: the official argued that there were already provisions in the Common Rule that could handle QI studies, and no overhaul of the regulations was necessary or desirable. If IRBs fail to implement the provisions or if they are not reviewing applications fast enough, that is their problem, and not problems with the Common Rule itself. I had to admire someone willing to stand up for their organization's mission in a room chock full of discontent.


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