Vaccines: Modern Trolley Car Dilemmas

The Trolley Car dilemma is back in bioethics news. For those unfamiliar with the trolley car dilemma, you alone are responsible to operate a trolley track switch to divert an out-of-control trolley car away from five workers on one section of track only to cause the death of a lone worker on the only alternate section of track. The dilemma: someone is going to die, and you get to decide who. In a recent editorial in the June 13th New England Journal of Medicine, Dr. Lisa Rosenbaum nicely describes the utilitarian dilemma surrounding the public health risks and benefits associated with a vaccine for the dengue virus, a mosquito-borne virus that annually causes significant severe illness and death worldwide. The dengue vaccine, Dengvaxia, is a real-world trolley car dilemma. Dengvaxia presently can protect large numbers of patients from this deadly virus, but at the expense of causing severe illness and death in a much smaller number of patients, mostly children.

Dr. Rosenbaum describes our response to utilitarian thinking, correctly I think. We don’t mind utilitarian rules that negatively affect others, particularly when the rules tend to confer benefit to our group as a whole (the very definition of utilitarianism) but we resist utilitarian thinking when it threatens to affect us negatively as an individual despite overall benefit to the rest of our group. Healthy self-interest often conflicts with the utilitarian calculus that purports to determine the overall benefit to the group. In the case of Dengvaxia, if the deaths caused by the vaccine only occurred in people who would have died from the natural dengue virus anyway, there would be no problem. In other words, by golly, you all were going to die from the widespread disease anyway, and since the vaccine did save some of you from dying, there is really no new or additional loss. Net positive outcome, right?

Sadly, vaccines do not work that way. With Dengvaxia, it may be possible to create a pre-vaccine test for seropositivity for the virus. This would mean determining whether a person previously had a very mild case of the virus such that they would not suffer a catastrophic outcome from receiving the vaccine, thereby allowing them to safely receive the vaccine to prevent a more severe case of dengue in the future. Such a screening test may be possible but it would cost some unknown amount of additional money and would still not be 100% accurate. Even so, no vaccine is 100% safe.

How many lives would need to be saved and at what cost before we are satisfied with the cost/benefit ratio of Dengvaxia (or any vaccine for that matter)? Presently the World Health Organization is recommending a pre-vaccination test be developed and only vaccinate those who test positive for prior exposure. This is effectively saying that the vaccination is not only not required but not even presently recommended in endemic regions, this despite the fact that Dengvaxia clearly significantly reduces overall mortality and morbidity. If the disease were more contagious and more lethal than dengue, at what point does the vaccine, however imperfect, become mandatory? This is the ultimate trolley car switch for public health officials.

Aren’t trolley car dilemmas fun?

Care Dis-integration

The May 3rd edition of the New England Journal of Medicine brings us a powerful story. It is a tale of a patient, named Kenneth, written by his physician brother.

Central to the story is a delay in diagnosis, brought on by unfamiliarity with the patient as a whole person, biases against those with mental illness, presumptions and other errors familiar to those of us with an inside view of what can go wrong. The healthcare system allows these to occur through its “dis-integration.” From the story:

Rosenbaum highlights the larger problem: “Care integration is an attitude.” But this “attitude problem” affects countless U.S. patients, not just those with mental illness (or severe physical disabilities, like quadriplegia).Whose attitude, then, needs adjustment? Many doctors and nurses seethe about the profit-driven dis-integration of our health care “market” yet insist they can’t fix this mess themselves. Kenneth, no stranger to cognitive dissonance, said, Well, if they can’t fix it, who the hell can? This question becomes more urgent as our health care system’s balkanization becomes increasingly “normalized.”

I have just seen this up close. A friend of mine has a terminal illness. While he has long been well-served by his family physician, the onset of the illness brought specialty care, extensive and repeated imaging, hospitalizations, a rehabilitation facility, and no more contact with his physician. It also brought delayed diagnoses which seemed avoidable had he been seen regularly by someone who knew his story and his usual condition.

Wasn’t such familiarity what we always had hoped would come from the “specialty” of family medicine? And that years of familiarity would lead to an understanding no stranger could have? Such an understanding would give us what we longed for in medicine, such as more efficiency, avoidance of excessive and intrusive testing, smoother transitions of care, more acute perception of changes (and quicker diagnoses), and better advice.

Increasingly, however, the family physician of today can no longer fulfill the promise of the profession from decades past. Financial constraints keep him in the clinic exam room, efficiently churning through patients within a narrowing scope of practice— no longer on the wards, or in the nursing home, or performing obstetrics, or even seeing children under two. Unable to venture out because time (equals money) would be lost, he is no longer involved in the care of his patients when they need something beyond his clinic. And it is in those intense moments that he is needed the most.

I would like to have a simple answer. Kenneth’s question stings: “Well, if they can’t fix it, who the hell can?” The financial pressures are enormous, however. Costs are up for countless reasons, and to keep the money flowing, a physician becomes the engine that must keep running… inside the engine room that is the modern day clinic.

Perhaps nothing short of a major disassembling of our medical system will change that. Such change may only come from catastrophe; even then any rebuilding would take a level of insight and courage…and preparation…that are unlikely to appear in future leadership under modern pressures. If we’re ever to move toward a dream of “care integration,” however, we’ll have to start somewhere– with understanding where we are, how we got here, and where we ought to go.

One Man’s Trash is Another Man’s DNA Treasure

Last month, investigators used big data analysis, public DNA genealogy websites and “Discarded DNA” to identify the Golden State Killer (WSJ subscription needed), an individual believed responsible for over 12 murders, greater than 50 rapes and over 100 burglaries in California between 1974 through 1986. While justice may be served if the legal case remains solid, there are some interesting bioethical issues that warrant discussion.

This blog has previously discussed the ethics of searching reportedly anonymized databases and the ability of algorithms to “unanonymize” the data (see HERE and HERE). The current technique used in the Golden State Killer case takes this one step further. Using a public genealogy database site, where individuals looking for distant relatives voluntarily share their personal DNA samples, investigators looked into these databases for partial DNA matches. A partial DNA match means that the investigators were looking for any relatives of the original suspect hoping to gain any identifying information of the relative, leading back to the original suspect. Then, using this narrower group of DNA relatives, investigators literally collected DNA samples this group of people unwittingly left behind, such as skin cells on a paper cup in the trash, so called discarded or abandoned DNA.

One man’s trash is another man’s DNA treasure.

Presently, neither the method of partial DNA search of public voluntary genealogy databases nor the collection of discarded DNA samples violates the 4th Amendment regarding unreasonable search and seizure. Neither the Health Insurance Portability and Accountability Act of 1996 (HIPAA) nor the Genetic Information Nondiscrimination Act of 2008 (GINA) provide protection as none of the data relates to health care records or employment, respectively.

Shouldn’t some law or regulation prevent my personal DNA code from becoming public, particularly if I have not taken steps to publicize it on one of the many public voluntary genealogy sites?

Since your DNA is the ultimate physical marker of personal identity, how much control do you or should you have over it? While you may wish to live a life of anonymity, your extroverted cousin who voluntarily provides her DNA to a public DNA database has just unwittingly publicized some portion of your family DNA as well as traceable personal family data that may allow others to know more about you than you desire. An energetic sleuth dumpster-diving your trash can retrieve your actual DNA. I shred my mail to avoid my social security number or other personal financial information from being obtained and used for identity theft. How do I “shred my DNA” to prevent it from being similarly recovered from my trash?

What may someone do with my DNA information obtained using these techniques. What should someone be able to do?

You could not have convinced me back in 2001 that anyone would spend money to build cars with 360 video equipment and figure out optimal routes that would eventually become what is now Google Street View. Might not someone do the same thing with trash-sourced DNA samples, perhaps Google DNA View?

We already have figured out the garbage truck routes.

My Day at the Florida Bioethics Network Conference–2018

For the past several years, it has been my privilege to attend the annual conference of the Florida Bioethics Network.  As in prior years, this year’s conference showed the great range of topics that fall under the umbrella of bioethics.   Topics included the so-called “Tattoo DNR,” a discussion of medical marijuana, the potential promise of an electronic and interactive informed consent document, and even a discussion of the role of clergy on ethics committees.  Each of these topics could merit a blog post, but the one that grabbed my attention the most was the discussion of “Public Health” by Celeste Philip, Florida’s Surgeon General and Jeffrey Brosco, the Deputy Secretary of Children’s Medical Services for the Florida Department of Health.

In an increasingly divided country, the concept of public health seems more remote than ever before, yet the presenters made it clear that it is a goal worth pursuing.  After all, “Your zip code is a better predictor of your health than your genetic code,” they argued.  With the prevalence of the 23 & Me-style genetic testing, their statement took me by surprise. After giving it some thought, their point was clear.  Addressing public health is an important function of government, they stated, and if the disparities between zip codes continue to grow, our health care system will be facing even more serious challenges than ever imagined. They claimed that the greater the inequality there is in income in a community, the greater the mortality – for everyone.

Both Drs. Philip and Brosco used the ethical concept of justice (which they used alongside “accessibility”) to underscore their case for a robust public health system.  Understanding that there is an ongoing tension between community protection and individual autonomy, they made a case that “Public health ethics requires both identifying the values that underlie policy as well as optimizing the language we use to convey available options.” (If you haven’t seen this already, in 2010 The Robert Wood Johnson Foundation published an article entitled, “A New Way to Talk about the Social Determinants of Health.”

I found the presentation to be both thoughtful and thought-provoking, going beyond many of the typical bioethics conversations that I encounter on a day-to-day basis. Those committed to a Christian worldview would do well to engage in this discussion.

 

 

Belgian Euthanasia: Volunteers No Longer Necessary?

A recent resignation letter by one member of Belgium’s Euthanasia Commission suggests the slippery slope of who meets the criteria for legal euthanasia is becoming even more slippery. Dr. Ledo Vanopdenbosch sent his resignation letter to members of the Belgian Parliament who oversee the commission. His concern was with one of the main requirements of the law, which demands that the individual patient formally request euthanasia. Vanopdenbosch claims euthanasia occurred on a psychiatric patient without his or her request. His resignation has generated substantial concern not only because Vanopdenbosch is a committee member but also because he is considered a strong advocate of euthanasia. Here is the AP article in Voice of America with the details.

One of the main tasks of the Belgium Euthanasia Commission is to review every euthanasia case to make sure each case meets the legal criteria necessary for euthanasia. Any case in doubt is referred to the public prosecutor’s office. It is perhaps telling that in the last 15 years since legalization of euthanasia in Belgium, over 10,000 individuals have been euthanized but only one case has been referred to prosecutors by the commission with the concern that it may have been performed illegally. Vanopdenbosch argues that the commission is acting in place of the courts, a potential conflict of interest given that those on the commission are generally considered strong supporters of euthanasia. In addition to the slippery slope metaphor used earlier, one might also add that the foxes are guarding the henhouse.

An internal review of this particular case resulted in the committee claiming that what really happened was an accidental death related to palliative care rather than actual involuntary or non-voluntary euthanasia, as is claimed by Vanopdenbosch. The general population will never know, as commission protocol and privacy concerns prevent the details of the case from ever reaching the light of day. In absence of further details, one wonders whether the alleged palliative care for the unknown psychiatric condition was formally requested by an otherwise competent patient or just provided absent his or her formal consent but “in his or her best interest” by the patient’s physician or caregivers.

It is presently unknown whether or not Dr. Vanopdenbosch’s resignation will result in any changes in the structure, function or transparancy of Belgium’s Euthanasia Committee. At the very least, one would expect to see an increase in referrals to the public prosecutor’s office for legal oversight. It is simply unbelievable that the committee has only encountered one case out of 10,000 cases that they found sufficiently suspect to refer to prosecutors for legal review. Perhaps more importantly, I want to believe that even those supporting euthanasia would be against all forms of non-voluntary euthanasia, particularly involuntary euthanasia. Sadly, I am naive. In our post-modern world, how can any death be a “good death” unless, at the very least, the competent patient in question so stipulates?

(For an excellent recent YouTube interview containing a brief history of euthanasia, please see this link of an interview with Dr. Richard Weikart, Professor of History at California State University, Stanislaus. Some highlights: at 10:40 where he touches on Belgium and psychiatric euthanasia, at 19:00 where he discusses the slippery slope argument, and at 21:30 regarding non-voluntary euthanasia)

Will Medical Compliance Ever Become Non-Voluntary?

A recent article by Dr. Lisa Rosenbaum in the New England Journal of Medicine explored both the benefits and drawbacks of Digital Adherence Monitoring. The focus was on the FDA’s recent approval of Abilify MyCite, a medicine technology that combines the medication aripiprazole, used to treat various psychiatric diseases such as schizophrenia, certain features of bipolar disorder and depression, with a digital ingestion tracking system. This voluntary digital health feedback system (DHFS) works by having the patient wear a skin patch that is triggered when the pill contacts the acid in the stomach. This event is then recorded and tracked on the patient’s smartphone. The patient can then permit their caregivers and/or physicians to access the data via a web portal. The company responsible for the DHFS, Proteus, has shown improvement in patient’s systolic blood pressure using DHFS compared with standard care. The article primarily focuses on using the technology to help doctors work with their patients to determine the reasons for non-compliance.

While this presently voluntary technology obviously can track pill ingestion and this data can certainly help doctors and patients improve medication treatment adherence, I wondered about non-voluntary uses of the technology. This particular DHFS confirms that the prescribed pill was actually ingested regardless of what the patient or their caregiver may claim. Would an insurance company be permitted to have access to this data in exchange for payment for a particularly expensive medication? Could a government agency require such a system in exchange for providing coverage for a patient for a procedure whose subsequent outcome is improved with the use a given medication?

Dr. Rosenbaum offered in her article that she thought it unethical to withhold coronary artery bypass from one of her patients with whom she was fairly certain would not subsequently take the dual antiplatelet therapy post revascularization. Using a DHFS eliminates mere suspicion. Prematurely discontinuing of thienopyridine therapy (antiplatelet drugs such as Effient, Ticlid, or Plavix) after a similar cardiac stent placement has been shown to increase the risk of both re-hospitalization and death within the subsequent 12-month period. Given the success of the Proteus DHFS in reducing systemic high blood pressure, mandating this DHFS to monitor antiplatelet therapy immediately post cardiac stent placement should reduce both patient morbidity and mortality during the following 12-month period.

A consequentialist in charge of public health care expenditures might disagree with Dr. Rosenbaum regarding the ethics of providing a revascularization procedure in an individual who is poorly compliant with beneficial post-procedure medication compliance. Bluntly, why spend the money if the patient (for whatever reason) is going to act in a manner to reduce the benefit of her procedure? Thankfully, money is not the only healthcare utility worth measuring and economists are not yet fully in charge of healthcare delivery, though they appear to have an ever increasingly important seat at the table.

So, I think DHFS technologies such as Abilify MyCite will slowly become non-voluntary.

Racial inequalities in cancer survival

Three studies published in a supplemental issue of the journal Cancer this month come to disturbing conclusions: in the United States, the survival rates for colon, breast, and ovarian cancer are lower for black people than for white people.

The news isn’t all bad: overall cancer survival rates are going up. The three studies mentioned here draw from two larger studies of worldwide cancer survival, the CONCORD study, published in 2008, and the CONCORD-2 study, published in 2015. Between CONCORD and CONCORD-2, cancer survival increased across all groups. But in both studies, the survival of black people in the United States lagged behind that for white people by about 10%.

Now there are certainly many reasons for the difference. Black people may be getting diagnosed with cancer at later stages, when survival is lower. There may be differences between the two groups, like genetic factors or the presence of other illnesses, that cause the cancers to be more aggressive in blacks. Mistrust of the health care system is more common among black patients, so they may be less likely to access care or access it early enough.

But other reasons include socio-economic status and access to health care; those who can’t access medical care because they can’t afford it or because it is not available nearby are less likely to receive necessary screening and treatment. And most troubling is the “consistent finding that black women do not receive guidelines-based treatment compared with white women, even when treated within the same hospital.”

The situation is too complex for simplistic answers; one can’t say from these studies that doctors are individually practicing blatant racism, and there is after all such a thing as systemic racism. But the medical profession should take such findings seriously, and seek every available avenue of education and self-monitoring to ensure that of all the places people encounter racism, the health care system is not one of them. And Christians especially, who believe that God created all people with equal dignity because all of us are created in His image, should work towards a health care system where the value — or length — of one’s life does not vary based solely on the color of one’s skin.

Uterine Transplantation – for Men?

Susan Haack began exploring the topic of uterine transplantation in women on this blog back in February 2014. In just under 4 short years, the technology has not only successfully resulted in live births in several women who received the uterine transplants, but outgoing president of the American Society of Reproductive Medicine, Dr. Richard Paulson, is suggesting we consider exploring the technique in men. While there are certainly hurdles to overcome (need for cesarean section for the actual birth, hormone supplementation, complicated nature of the transplant even for cisgender women), Dr. Paulson does not consider these barriers insurmountable for transgender women.

Dr. Julian Savulescu, professor of practical ethics at Oxford, has cautioned that initiating a pregnancy in a transgender woman may be unethical if it poses significant risk to the fetus. The above-linked article misquotes his concern as a concern over “any psychological harm to the child born in this atypical way”. The following is his actual quote from his own blog:

Therefore, although technically possible to perform the procedure, you would need to be very confident the uterus would function normally during pregnancy. The first US transplant had to be removed because of infection. There are concerns about insufficient blood flow in pregnancy and pre-eclampsia. A lot of research would need to be done not just on the transplant procedure but on the effect in pregnancy in non-human animals before it was trialled in humans. Immunosuppressives would be necessary which are risky. A surrogate uterus would be preferable from the future child’s perspective to a transplanted uterus. Uterine transplantation represents a real risk to the fetus, and therefore the future child. We ought to (other things being equal) avoid exposing future children to unnecessary significant risks of harm.

One putative benefit might be the psychological benefit to the future mother of carrying her own pregnancy. This would have to be weighed against any harm to the child of being born in this atypical way.

His concerns are the baseline medical risks involved in using a transplanted uterus to conceive a child regardless of the sex of the recipient. None of his concerns relate to the psychological harm to the child potentially caused by a uterine transplantation in a transgender woman as opposed to a cisgender woman. Savulescu is explicit in the beginning of his blog that “[t]he ethical issues of performing a womb transplant for a [sic] transgender women are substantially the same as the issues facing ciswomen.” Is the only risk to the child “born this atypical way” just the additional need for hormone supplementation in the transgender woman compared to the cisgender woman? Can we really know, a priori, what all of the attendant risks to the child really are with uterine transplantation in a transgender woman?

Regardless, let’s assume Savulescu is correct, that there is indeed no ethical difference between carrying a child to term via uterine transplantation between a cisgender woman and a transgender woman. There certainly can be no ethical difference between carrying a child to term via uterine transplantation between a transgender woman and a cisgender man. If the foregoing is true, can there be any ethical barrier preventing a man via uterine transplantation to use his sperm to fertilize a donor egg and carry his baby to term? After all, per Savulescu, all we need be concerned about from a bioethical standpoint are the technical issues/risks of uterine transplantation regardless of the recipient’s biological sex or self-identified gender.

In Genesis, God created two complimentary sexes and stated this difference was good. We are moving toward eliminating differences between the sexes and arguing that this is good. Both of us cannot be correct.

I wonder if Dr Haack thought that we would get this far down this particular bioethical slippery slope in four short years?

Dr. Smartphone

My brother tells me my doctoring days are done. We keep up a lively, ongoing email discussion of current technologies as they relate to topics such as big data analysis, Internet of Things (IoT), and smartphone technology. He recently challenged me that due to the rapid increase in computational power and sophistication of data analysis, smartphones will soon replace doctors as the main source of medical diagnosis. He is probably correct. But will my doctoring days be over?

Consider the linked article by Madhunita Murgia in The Financial Times (you may get one view of this unless you have a subscription or Google “Murgia smartphone”). Murgia lists a fairly exhaustive list of both current and looming smartphone apps and smartphone attachments that are – frankly – amazing. A fair number of these are backed by technical and clinical staffs, as well as massive computational clouds, that provide analysis of what you and your smartphone observe – about you. By keeping track of the number of calls you initiate, your movements (or change in that number), the quality of your voice, the results of heart EKG sensors on the phone cover and voluntary responses to personalized texts, your smartphone can instantly analyze your current physiology and often correctly identify any pathophysiology better than some (most?) physicians. Given the IoT technology trajectory, the smartphone will only get better and do so at a far faster and broader pace than the average MD during his or her limited 30 years of solo or group practice experience. It is the medical “Wisdom of the Crowd”, to borrow from a current TV show. Read the above linked article (if you can) just to get a glimpse of what is already here and what is quickly going to be available.

Security and privacy issues may be the one limiting factor in this technological progress. Consider one example of current technology in the area of smartphone post-partum depression diagnosis and management. A company called Ginger.io has developed a smartphone-based tool for patients to use to identify depression by a series of interactive text questions with a company coach as well as raw data from your phone checking the number and length of phone calls to friends, as well as an analysis of quality of your voice (no actual content – yet). Joseph Walker at the Wall Street Journal (subscription needed) offered one patient’s experience:

Tara Dye, who participated in Novant’s postpartum program, said she wasn’t aware of the extent to which her smartphone data was tracked. Ms. Dye says she was told the app would record her location and how far she traveled, but she didn’t realize that her behavior was being probed for a link to depression. She says she doesn’t mind the extent of the tracking, because it was in service of her health care, but she wishes there had been greater disclosure.

Finally, Andy Kessler, also at the Wall Street Journal, argues we are too worried about all this smartphone monitoring. He believes that eventually courts will rule that use of our personal data (heart beats, facial recognition, voice quality, etc…) will be determined to be a property rights issue and eventually companies such as Ginger.io and Apple will have to pay you for the use of your personal data. That may well be. But it does not currently put the “data horse” back in the privacy barn.

I am not sure where that leaves me or the other average doctors as smartphones eclipse us in diagnostic acumen. Like most technological advances during my practice lifetime, I have worked to embrace the ones that work and sifted through and discarded the ones that did not. Will there still be a place in the practice of medicine for one-on-one, patient-doctor relationships? An 87 year-old patient of mine recently commented to me that although I had not significantly improved her chronic back pain, she appreciated the time I took, the education I provided, and the reassurance that her problem was not more severe. Perhaps she was just being nice.

My brother would argue the smartphone would have been faster, cheaper and avoided the risk of her traveling to my office. I’m not sure. Let me ask Dr. Siri…

Mental Health ERISA Law for Dummies

My son is an ERISA attorney whose present work requires him to make sure that large group insurance plans offered by companies comply with various federal statutes, such as the various regulations surrounding the PPACA (i.e. ObamaCare). In one of our recent discussions about healthcare access, he made me aware of some federal laws regarding the provision of mental health benefits, which I was heretofore completely ignorant. In my practice, I have frequently been frustrated by trying to get mental health care for some of my patients, some of whom appeared to have reasonable health insurance, which turned out to have rather minimal mental health coverage, a condition ERISA nerds refer to as lack of coverage parity between mental health benefits and covered medical and surgical benefits. This is thankfully changing. Without getting into the tedious minutia of ERISA law (and it is very tedious), let me take you on an abbreviated tour of these mental healthcare federal statutes.

Prior to 1996, coverage for mental health care was unambiguously less generous than for physical illness. In 1996, the Mental Health Parity Act (MHPA) passed, which required parity of annual and aggregate lifetime limits compared to med/surg benefits. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) expanded parity to include treatment limitations, financial issues such as co-pays, and in- and out-of-network coverage. However, and this was and continues to be a major “however”, neither of these federal statutes mandated any specific mental health coverage but simply required insurers who chose to provide mental health coverage to do so with parity with other medical and surgical benefits. I like to think of this like Title IX established parity between the sexes, MHPA and MHPAEA tried to establish parity for mental health with other medical coverage. If you want to get into the minutia, begin HERE and HERE.

With passage of the PPACA in 2010, both MHPA and MHPAEA suddenly developed some teeth. The PPACA mandated coverage of certain mental health and substance abuse disorders. Now the benefits for those covered services must have parity with other medical and surgical benefits. For a deeper dive, see HERE. But oddly, the sharpness of MHPA’s and MHPAEA’s new teeth varies by state. For technical reasons that only an ERISA attorney may understand, there remain variations in state-by-state interpretations of the coverage minimums of the PPACA 10 ‘required’ Essential Health Benefits (EHB), so see HERE for more details (particularly chart at bottom of linked article listing benefits by state).

Nonetheless, armed with these statutes, mental health advocates are demanding their parity. Recently, the 2nd US Circuit Court of Appeals allowed an ERISA lawsuit to proceed against a large health plan group administrator for their alleged reduction in mental health benefits for services provided to patients. Whether this encourages other legal challenges for more parity, time will tell.

What does foregoing mean from a bioethics standpoint? This blog has frequently discussed the problems of healthcare access for some our most vulnerable members of society, many of these related to mental health struggles. While I am no fan of the PPACA in general, this is one result that I applaud. More work needs to be done to determine exactly what mental health issues get covered and perhaps who gets to decide. Until we all behave like the Good Samaritan toward all of our neighbors, it may take statutes like these to nudge us along the way.