Monday, April 2, 2012

Fear in the Media: Why Dick Teresi's Newest Article Reminds me of the MMR Controversy

In the science writing course that complements this blog, we've spent a lot of time discussing the MMR-vaccine controversy and the sometimes severe consequences of sensational media coverage. In the late 90's, Andrew Wakefield infamously linked autism to vaccination in The Lancet. Wakefield's paper was later retracted and condemned by the medical community for its fraudulent methods, and Wakefield himself was eventually struck from England's medical register. But the damage was already done; despite a complete lack of evidence that vaccines cause autism, a strong anti-vaccination movement continues to threaten both individual and collective immunity to infectious diseases.

Earlier in March, the Wall Street Journal ran an article written by long-time science journalist Dick Teresi in anticipation of his new book, The Undead. Teresi's WSJ piece --"What You Lose When You Sign That Organ-Donor Card" --has met a lot of resistance in the brief time since publication, and it reminds me more than a little of media response to the MMR debate.

Teresi's troubling new book, The Undead

The article opens with a personal confession: Teresi is not a registered organ donor, and he's not sorry. In fact, his mordant self-deprecation implies that he knows something we don't. Without missing a beat, Teresi suggests that organ donation is a deceptive process --that it somehow operates against the principle of informed consent because current standards for declaring death are insufficient.

Brain death is an irreversible cessation of lower brain function; it is unlike a coma in that recovery is not possible and also unlike a permanent vegetative state in that sporadic breathing and movement never occur after brain death. Truly brain-dead patients will not breathe on their own or respond to basic stimuli. Most cases of brain-death follow localized, traumatic head injury, which often leaves other organs  unharmed and healthy enough to donate. Organ recovery is a rapid process, but surgeons and physicians can ease the time crunch by using a ventilator to artificially maintain circulation and respiration in the deceased until they can safely transplant the organs to another patient.

Teresi has a problem with the idea of post-mortem organ donation, especially when it comes to deciding when "post-mortem" is. Most of all, Teresi doubts the adequacy of current standards for determining brain-death before organ retrieval.  "The exam for brain death," Teresi begins, "is simple." He describes a few of the exam's parts: "splashing" icy water into the ears, "poking" the eyes with a cotton swab, and other "rudimentary tests...[that] take less time than a standard eye exam". Language is vital in editorial construction, and the language that Teresi uses to describe brain-death testing is flippant and dismissive. He portrays the straightforward procedure in a negative light (i.e. "That's all it takes?") instead of emphasizing the true implications of the test's simplicity (i.e. If a person is unable to respond with a basic, involuntary reaction to an eye stimulus, there is virtually no hope for a recovery of brain function and an acceptable quality of life thereafter). Teresi, somewhat bewilderingly, presents very old papers and agreements as supporting evidence--he cites, for instance, the committee meeting in 1968 that first proposed the basic core of modern brain death criteria --without mentioning that the criteria are reexamined and updated constantly.

Taken together, Teresi's points undermine long-standing medical opinion that determination of brain-death by the proper criteria is very thorough and almost always accurate. He challenges the authority of the American Academy of Neurology (AAN) when mentioning, without context, that certain components of the brain-death exam have been eliminated from protocol over the years. That kind of indirect criticism is just enough of a nudge to the audience to convey a quick, blameless, "Look, I'm no expert, but I'm just saying...isn't it interesting?" He never explains that these components (I'm thinking of EEG here, specifically) have problems with false readings and inconsistent results.

One paragraph of the article floored me with its subtle subversion of the fact that some spinal reflexes can occur without a functional brain:
"But [beating heart cadavers] --who don't receive anesthetics during an organ harvest operation --react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates. Doctors say these are simply reflexes."
Despite a firm medical consensus that brain death is irreversible, Teresi implies that slight electrical brainwave activity and occasional reflex motor movement are a ray of hope for recovery. The article's most explicit mention of possible recovery from brain death comes with an allusion to a 1999 peer-reviewed article from the journal Anesthesiology, in which the author Van Norman reports that a patient regained breathing function after brain death. Van Norman's paper intrigued me for two reasons; first, the 2010 AAN report is emphatic in its claim that no one on record has ever recovered from brain death, and second, the anecdote presents a very strong, emotional claim as touch-and-go fact. So, I tracked down an old copy of Van Norman's article, where I immediately found the context for the patient described in Teresi's article (italicized emphasis mine):
"During an educational course for anesthesiologists, a participant described a case (not independently verified by the author) in which a 30-yr-old patient was admitted to a level 1 trauma center with severe head trauma."
Teresi conveniently omits Van Norman's contextual disclaimer, along with her reservations about the reliability of the EEG test that Teresi himself so fervently pushes.

What might be the effect of one journalist's public discouragement of organ donation? At first, I wasn't sure if the WSJ article deserved the attention of a careful criticism at all --so poor was the construction of this piece. I changed my mind after noticing a review of Teresi's new book in the NYT, and another (less controversial article) chosen as an Editor's Pick at Clearly, someone is paying attention to Teresi's articles on this subject. Even after the WSJ followed the article with a scathing letter to the editor written by a group of bioethicists and doctors, I'm afraid (and others are, too) that organ donation could suffer from Teresi's sensational portrayal of the process and motivations surrounding it. He has, among other things, exacerbated the #1 myth of organ donation --the unfounded worry that a doctor could hasten the death of a patient to harvest organs.

And the unfortunate part of all this is that Teresi's subject, had it been handled by a more skillful, impartial author, would have been a fascinating one to read about. The definition of death has changed as we've gained the ability to sustain life by artificial means for a very long time. I personally have a great academic interest in questions of end of life treatment, palliative care, and the contemporary euthanasia debate; these kinds of questions loom large in today's bioethical literature. Teresi had a great opportunity to apply philosophical conversations to practical healthcare policy in an accessible media venue. Instead, he confused scientific consensus with ethical debate and acted irresponsibly as both a science communicator and a journalist, potentially endangering the organ donation movement by stirring public fear.

The most interesting (and regrettable) aspect of this for me is the irrevocability of articles like Teresi's once they've been released. We have seen the lasting effects of Andrew Wakefield's ill-fated paper and its sensational coverage in the news. Once something is published, it can never be fully erased from public conscience. And one of the last-standing safeguards, it seems, is for an article like Teresi's never to have been written, published, or discussed with any seriousness at all. News outlets like the WSJ have a heightened responsibility to fact-check where obvious issues of public health and safety are involved. The WSJ editors dropped the ball on this one.

Journalists have an obligation to handle their topics with objectivity. This means providing proper context, word choice, and tone. This means consulting the right people for fact-checking and quoting them accurately. Most importantly, this means avoiding sensationalism, even when it will almost guarantee an article's popularity.

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