I'm so happy when I read this that my work does not include decisions as grave as these. The medical profession is not short of heroes, but you'll hardly ever know about any of this, this article is a great example of that. I know one woman who works in a hospital that tends to children with cancer, I can pretty much read how her charges are doing by looking at her. And nobody will ever read about her in a newspaper.
I used to be a teacher in Baltimore City, and I used to say, it's the most stressful job that doesn't come with life-and-death decisions built in. I say "built in", because I did have to deal with the consequences of death outside the school building several times.
In any case, I really don't miss it. Some of my days were so insane that I realized at some point that I seemed to be subconsciously wiping my memory of it at the end of the day. Even as a founder trying to launch a startup, my craziest days paled in comparison.
Not saying my experience is anything like separating a conjoined twins or dealing with pediatric cancer, but just that I can relate to your thankfulness of having a job that's not that intense, by any measure.
I went to the east coast for the cyber boom and ended up doing IT contracting for the City of Baltimore school system. I saw a large amount of the schools and it was one of the most eye-opening and saddening experiences I've ever had... and I'm an Iraq war vet. So don't discount your experience there. Baltimore is not normal. Coming from Texas where at least I can concealed carry I had a couple of really fucking hairy incidents that really bugged me that I had no way to defend myself.
I wouldn't live there if you payed me, and certainly never with a family.
Side note, did you hear about the cop who was going to testify against the PD and ended up dead? The PD there is corrupt as fuck.
> The fabricating-evidence charge is a misdemeanor, which carries a maximum penalty of three years’ imprisonment and a $5,000 fine. Misconduct in office is a common-law offense, which means that the court is free to impose any penalty that does not constitute cruel and unusual punishment.
> Prosecutors said the video prompted them to drop more than 110 cases involving the three officers in the video from Pinheiro’s camera.
That's 110 people who either were innocent and terrorized by the police, or were guilty and escaped justice due to police incompetency. Either way, not a good look.
Prosecutor in this case the same State's Attorney Mosby who tried (and failed miserably) the Freddie Gray manslaughter/murder case.
>That's 110 people who either were innocent and terrorized by the police, or were guilty and escaped justice due to police incompetency. Either way, not a good look.
To play devil's advocate: If you're going to reason that way, you should also consider the number of actual criminals who were punished only because of planted evidence.
I'm not advocating corruption - I still think it probably warrants the death penalty due to its cancerous and widespread impact on innocent people.
No, because it's a decided question. As a society, we've already chosen that we'd rather see a perpetrator walk free than imprisoned without proper evidence.
We shouldn't have to revisit that decision on the merits just because some police officer who disagrees with it unilaterally breached the social contract. We should just punish him. Severely.
It sounds like you're suggesting that ethical reasoning done by previous generations is somehow binding on future debates, almost like some form of case law.
> As a society, we've already chosen that we'd rather see a perpetrator walk free than imprisoned without proper evidence.
I wonder if you're failing to make a distinction between what people will say in public vs. their private thoughts on the matter.
I heard the stories from my brother, who taught at inner-city schools in Charlotte for a while. He stayed longer than almost anyone else his age at the job, but eventually he couldn't bear it anymore.
He's a much stronger man than I. I wouldn't have lasted a week.
One of my best friends growing up went to a high school in Baltimore City. It was absolutely _incredible_ how many students and parents he knew that had died. I commend you for working there as long as you did. It's really unfortunate how terrible those schools can be. My friend said it was very rare to see a teacher last longer than a year or so, too. They would get scared or hurt and quit.
Do No Harm by Henry Marsh is a great book that gives some perspective on what it’s like to have to make these decisions. In both their success and failure.
So, re-reading this and running the numbers it looks like a classical example of an un-necessary expensive procedure (and a risky one at that), could anybody with more medical knowledge comment on this?
0.05% per year chance for a person that is 32 years old leaves 50*0.05 = 2.5% chance of rupture during the remaining life of the patient, whereas the operation itself has a 5% chance of failure.
It's reminiscent of the downside of scanning for just about everything in patients without symptoms.
Well the failure is 4-5% and with increasing life expectancy she could have 60 years left (60*.05 = 3%).
Now you’re talking about a possible 1% difference and the negative affect on someone’s life from the anxiety of knowing they have an aneurysm. I also wonder if the operation is less risky with a younger patient. While it may have been better to never have known you have an aneurysm, once you do know the decision isn’t obvious to me.
He did offer his opinion for himself, but being older changes the equation. In her case she did have initial symptoms that lead to the scan, but they were likely unrelated.
Paternalistic medicine isn’t really a thing anymore so on these edge cases I think it makes sense to discuss the risks with the patient (which is what was discussed at the beginning of the story).
The downside of scanning for everything is that you'll end up increasing the cost of medicine considerably for extremely little gain. Case in point: breast cancer screenings catch a lot of malignant tumors in an early stage helping many patients before their cases become more serious. But the downside is that it has caused a large number of un-necessary procedures as well raising the costs and - and this is the kicker - blocking the available capacity with cases that would never become serious in turn denying that capacity to people whose cases are serious.
A bit of googling will give you lots of articles on the subject, the same kind of evidence exists for prostate and other cancer screenings as well as other diseases.
For another great book related to your breast cancer example check out The Emperor of All Maladies.
It’s a detailed history of cancer and spends some time talking in detail about how statistics determine at what age preventative testing makes sense given false positive risk.
That's a very stupid decision to make from her side. She had small children, so every additional year she lives is immensely important for her children. To die in the next year is just 0.05% probability, to die now - 5%. Even if she dies in 10 years, these 10 years of her life would have been an unmeasurable gift to her children comparing it with her dying on the operating table.
The surgeon had to do the math with her, instead of wondering, whether she understood the risks or not.
Unfortunately, many people are illiterate with numbers, so you cannot assume that in that person's head numbers like 5% and 0.05% do not both translate to "negligibly small".
>I'm so happy when I read this that my work does not include decisions as grave as these.
Yeah, I don't think I could take a (software) job where screwing up meant people die (or are even very seriously inconvenienced - e.g: airline booking systems), I don't want that responsibility on my head.
My props to the people who do the countless jobs where messing up means terrible things (in and out of software), and not just lost revenue and 'downtime'.
I've worked on software that controlled servo driven lathes and mills. I still know the e-stop function of that code by heart 30 years later, not because it was such an elegant or beautiful bit of code but mostly because I realized that any kind of fuck-up there would likely mean someone would lose a finger, a limb or even worse, and so I kept on re-reading it and inventing new ways to test it to ensure that it was solid. It definitely raises your level of awareness when you are working on stuff that has real-world consequences.
I should probably do a write-up on how this worked, it was a pretty creative solution to a very hard problem and as far as I know it never failed to work in production. The machines are still in use in some places after all these years, never ceases to amaze me how long lived some of those projects were. Atari ST as the hardware, software in a combination of GFA basic and 68K assembler, just about every port on it used to drive some output or read a sensor.
> I still know the e-stop function of that code by heart 30 years later
I'd be very interested in hearing more about this! I've recently re-designed the safety system for my company's product, and I chose to keep it purely hardware based (using safety relays) rather than involving any software, purely because it's so much harder to guarantee that software will be failsafe.
That's the perfect solution, and actually quite close to what I ended up doing. But you are still going to have to (1) detect the fact that there is an e-stop in progress, (2) restore the machinery to stable state afterwards and (3) lift the e-stop condition at some point.
And all of those will have a software component.
I've written a bit more about how it worked in another comment.
The big thing to keep in mind here is that an ST is a very limited machine when it comes to IO and that just about every port was already occupied so I somehow had to make this work safely without having additional ports for e-stop i/o in the budget.
If I had to do it again in the present I would never have consented to using such an I/O hamstrung platform to begin with and I would use an FPGA to do all the control logic.
> The idea of writing code that could put someone's life on the line is totally terrifying to me.
That's very reasonable :-)
I've worked on very safety-critical systems before. It's fun!
For one thing, you get to do things right. Sure, there are deadlines, but nobody dares to tell you to leave things half-baked. If it takes time, then it take time. Shoo, manager.
For another, you must dive deep into the behaviour of your embedded (mechanical/electrical/software) system and understand all its corner cases, even in the face of faults ("OK, so we're doing this operation, and now a cosmic ray hits and a crucial bit flips in RAM -- do we have a detection and safe reaction?")
Apart from the fun-ness, realise you're not in it alone. You'll be supported by a bunch of your fellow engineers double-checking your work, testing the system, etc., so your confidence in the system is quite high.
I tested the hell out of it to make sure that it worked as intended. Long story short, the hard part was to make sure that on powering up the system it wouldn't put random bits of output on the various ports which the hardware would then interpret as signals to make servos run and power up spindles. Initially I thought that the hard part was to make things stop, but that's actually rather easy, you just drop the power to a relay that is held 'on' by itself. That's irreversible from the software side, someone then needs to re-enable the power manually using the same mechanism (those mushroom switches stay down once you activate them). But when you do that - the re-enabling - you risk mayhem because the state of the machine is completely undefined. The trick to solving this was to confirm one-by-one that all outputs were in defined states and then outputting a sequence of bytes on a port to re-engage the relay, independent of whether the user had re-set the e-stop. The sequence was long enough that it could not happen by chance.
It's this kind of subtle interaction between hardware and software where it is super easy to make a stupid mistake and to end up regretting it the rest of your life. Making sure that machine stayed off when it had to was super important, some of those servos were the size of buckets and would happily rip your arm off when powered up, the chuck on the largest machine that we did was 6 meters, to cut wheels for harbor cranes. Really nothing to fuck up with.
Testing it was a long and labor intensive process with a first stage in simulation, then a second stage on a machine with all motors powered off except for the servos, then a run in 'air' but with a turning spindle and finally two real runs, one in aluminum and one in steel.
The electronics were tested separately, we found that one of the early mobile phones (ATF-3) was really good at getting latches to trip that shouldn't trip.
I learned a lot on that job, but it wasn't fun to work with the guy that ran that company, I wrote about this here:
I used to work with a physicist turned MD turned clinical geneticist who now primarily works with pediatric oncology.
I’m amazed not only by how bright and dedicated he is (he gave me his personal cell while I was working with his data), but by the enthusiasm and optimism he displays while working with children with horribly aggressive cancers.
It's interesting that in just about every country there are statues and monuments to the heros of war, but I've yet to see a statue for a nurse or a surgeon who - instead of taking life - give life.
It's not quite the same, but every Shriner's Hospital for Children has a statue out front of a Shriner carrying a polio-stricken girl and her crutches.
“Arguably Australia's most famous soldier is neither a general nor a Victoria Cross recipient, but a stretcher bearer who served briefly in the nation's first major campaign”
Hospitals not named after saints are more often than not named after rich people who like to have things named after them, not the people who sacrifice in those hospitals serving people.
Essentially, it was a real-life Trolley Problem [1] - do you actively kill one patient in order to save another? Or do you do nothing and “allow” them both to die? I don’t blame the doctors on either side for their decision to participate or not participate - it is an incredibly complex ethical decision.
Maybe I’m oversimplifying here, but is it really that complex of an issue in this case? The two of them together faced almost certain death. In most versions of the trolley problem, the potential victim of action isn’t going to die either way.
To me, the more interesting moral aspect of this is that a surgeon who hadn’t done this before accepted the case because it would be interesting and challenging. I’m only paraphrasing a little; that was basically his description of it in the article.
Yeah, the doctors I've talked to tend to say the same. A neurosurgeon seeing a MRI or CT scan of my wife's brain said it would be amusing to see her brain's tissues, but fortunately it was not needed.
I had a surgery in my hips which the doctor said the same, he wanted to do the surgery to improve his research and even asked me to use my files, anonymously obviously, in his presentations and research.
I think we all are interested in our work, and he said that every case is different, I'm not sure if experience would help much.
My first reaction was the same, but further down he mentions a team of 50 people involved in the procedure itself, including a couple of other doctors. This implies that the whole thing was a huge team effort, and not just a one man show for the thrill.
I do wonder how much effort it took in total to prepare this procedure. CT, MRT, research, rapid prototyping of bones and other structures for analysis and practice runs... it seems they used all the tools they could.
You are technically correct, but that still did not make any of it any easier, the doctor must have been fully conscious that severing the artery between the girls would lead to an end of the weaker one, especially after testing it by temporarily restricting the artery and seeing how fast the weaker girl went down.
(IANAD of course, just too much of Grey's Anatomy and House) i wonder why they didn't place her on bypass before the cut and didn't try to correct her heart or find a heart transplant for her.
Not really a trolley problem since the weaker twin is going to die no mater what you do, so the ethical responsibility is much diminished to hastening that death with a few weeks or months in order to save another life.
A real trolley problem would involve three conjoined twins, of which one has a good chance to outlive his siblings, yet an intervention exists that can save both of them by depriving him of critical organs.
I don't think it's complex. It's heartbreaking and sad. The Trolley Problem is a test of character more than an ethical problem. It separates people who are willing to take on responsibility from those who aren't.
This a fascinating and heartbreaking story. Medical science can produce miracles, and I'm grateful for the consideration given to the ethics of action.
This situation was recently dramatized by the television show The Good Doctor.
The ethical anguish there was compounded by making the patients old enough to tell the surgeons that they would rather sacrifice their own life to save their sister, than to be the sole survivor--who would then live only because her sister and lifelong constant companion is dead. The scriptwriters also stirred the pot by putting one in a coma to remove the possibility of explicit consent.
At the time, it stretched my suspension of disbelief.
I would have loved to to hear about the discussions and arguments around the ethics of their decision. I personally believe they made the ethically correct choice. It could be argued that by not operating they were violating some sort of 'do no harm' principal. By not operating they may have caused two girls to suffer (especially in the case that they both survived into adulthood). Very interesting and puts my work into perspective. Very humbling.
