UntitledDecision Making in Cardiac Therapeutics: Ethics, History, and PolicyProgram in Science, Technology, and Society, MITDepartment of Global Health and Social Medicine, HMSDavid S. Jones, M.D., Ph.D.11 February 2010Background image of operating room removed due to copyright restrictions.DISCLOSURE I have no financial relationshipwith a commercial entity producinghealth-care related products and/or services.Social Determinants of DiseaseSocial Meanings of DiseaseSocial Responses to DiseasePractice: Health Care DeliveryMedical Epistemology: how do we know what we knowWhat Is Social Medicine?Heart Attack Deathswww.worldmapper.org© Copyright SASI Group (University of Sheffield) and Mark Newman (University of Michigan). Used with permission.Courtesy of The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Used with permission.The best Rx for AMI is PCI? How do we know?Painting by Frank Netter, M.D. of man suffering from angina pectoris, chest pain due to coronary artery disease, removed due to copyright restrictions.Photo of coronary angioplasty removed due to copyright restrictions.0 100 200 300 400 500 600 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Mortality / 100,000 Year Mortality from Diseases of the Heart Age-Adjusted CrudeRisk Factors© R.J. Reynolds Tobacco Company. All rights reserved. This content is excluded from our Creative Commons license. For more information, see http://ocw.mit.edu/fairuse.Other Risks?Courtesy of World Health Organization. Used with permission. For complete publication, see Wilkinson, Richard and Michael Marmot, ed. Social determinants of health: the solid facts. nd ed. Copenhagen, Denmark: World Health Organization Regional Office, 2003. ISBN: 9789289013710.2CAD as a Disease of ElitesWarren HardingCalvin CoolidgeDwight D. EisenhowerLyndon JohnsonPhoto of President Dwight D. Eisenhower in wheelchair removed due to copyright restrictions.Race and Differential Susceptibility?Do not feel stress, or cannot handle itPublic domain photo from U.S. National Archives and Records Administration.How to treat coronary artery disease?Photo courtesy the National Heart, Lung, and Blood Institute.Excerpts from New England Journal of Medicine removed due to copyright restrictions. For complete article, see Sproull, John. "A General Practitioner's Views on the Treatment of Angina Pectoris." New England Journal of Med no. 10 (1936).icine 215,Reduce Demand:Disrupt sympathetic nervous system Courtesy of Elsevier, Inc., http://www.sciencedirect.com. Used with permission. Public domain image. Figure 4 from Jonnesco, Thomas. "La Résection Du Sympathique Figure 1 from Swetlow, George I. "Paravertebral Alcohol Block in Cervico-Thoracique: Technique Opératoire." La Presse Médicale, no. 33 (1922). Cardiac Pain." The American Heart Journal 1, no. 4 (1926).Reduce Demand:Thyroid Ablation (surgery, radiation)Excerpts from New England Journal of Medicine removed due to copyright restrictions. For complete article, see Blumgart, Herrman L., A. Stone Freedberg, and George S. Kurland. "Treatment of Incapacitated Euthyroid Cardiac Patients by Producing Hypothyroidism with Radioactive Iodine." New England Journal of Medicine 245, no. 3 (1951).Informal Claims of EfficacyPhotos of patient seven years before operation, and three years and six months after operation from Annals of Surgery removed due to copyright restrictions. For complete article, see Cutler, Elliott C., and Stanley O. Hoerr. "Total thyroidectomy for heart disease: A five-year follow-up study." Annals of Surgery 113, no. 2 (1941).77 patients: 36% cured, 32% improvedExcerpt from The New York Times removed due to copyright restrictions.For complete article, see "'Simple' Surgery Called Heart Aid: Physician Hopeful Method Will Help End Effects of Coronary Thrombosis." The New York Times, February 6, 1957.Excerpt from Journal of Thoracic Surgery removed due to copyright restrictions. For complete article, see Glover, Robert P. et al. "Ligation of the Internal Mammary Arteries as a Means of Increasing Blood Supply to the Myocardium." Journal of Thoracic Surgery 34, no. 5 (1957).Excerpt from American Journal of Cardiology removed due to copyright restrictions. For complete article, see Dimond, Grey, C. Frederick Kittle, and James E. Crockett. "Comparison of Internal Mammary Artery Ligation and Sham Operation for Angina Pectoris." American Journal of Cardiology 5 (1960).Excerpt and Table 1 from Journal of the American Medical Association removed due to copyright restrictions. For complete article, see Beecher, Henry K. "Surgery as Placebo: A Quantitative Study of Bias." Journal of the American Medical Association 176, no. 13 (1961).Increase Supply:Create or provide new conduits for bloodRe-engineering the body... Three figures of surgery to treat coronary artery disease removed due to copyright restrictions. See Beck, Claude S., and David S. Leighninger. "Scientific Basis for the Surgical Treatment of Coronary Artery Disease." Journal of the American Medical Association 159, no. 13 (1955). Figure 7 of interal mammary artery implantation from Diseases of the Chest removed due to copyright restrictions. For complete article, see Vineberg, Arthur. "The Bloodless Greater Omentum for Myocardial Revascularization." Diseases of the Chest 54, no. 4 (1968).Internal Mammary Artery ImplantFigure 7 from Annals of Surgery removed due to copyright restrictions. For complete article, see Effler, Donald B. et al. "Increased Myocardial Perfusion by Internal Mammary Artery Implant: Vineberg's Operation." Annals of Surgery 158, no. 4 (1963).Selective Coronary AngiographyFigures 1, 4, and 5 from Circulation removed due to copyright restrictions. For complete article, see Lemmon, William M., Stauffer Lehman, and Randal A. Boyer. "Suprasternal Transaortic Coronary Arteriography." Circulation 19 (1959).Mason SonesCine-angiography1958Photo of Mason Sones, c. 1960 at the Cleveland Clinic removed due to copyright restrictions.January 12, 1962: Visual Proof?Figure 9 from Annals of