Balkinization  

Tuesday, March 03, 2009

Does Calhoun still live?

Sandy Levinson

I was originally going to post what follows as a contribution to the discussion of my post below on the filibuster, but I decided to give it more prominence. One of the complaints (offered courteously, I might add) was that I am insufficiently attentive to the fact that we are intended to be a "republic," not a "democracy," and that my animus to the Senate (and then to the filibuster) denies this. I have addressed some of these complaints before, but it may be worthwhile to do so once more.

I agree that bicameralism is easily defensible, especially in large states or countries (like Texas, California, and the US), without this entailing equal representation of all counties or states. Senators can be elected from larger areas and serve longer terms. Moreover, I strongly support Larry Sabato's proposal that we add some "national" senators, either by election or by ex official appointment of, say, former presidents and vice presidents--yes, this would include George W. Bush and Dick Chency--and the like.

I agree, incidentally, that the filibuster is rarely purely small state-large state. And there are certainly some small states, like Vermont, where two Democratic senators counterbalance the two Republicans from Texas. And there is some pull to the argument that 47% of the electorate should not be ignored. The question, though, is whether 41% of the members in one house, who may or may not, depending on sheer contingency, represent anything close to even 47% of the electorate, should be able to veto legislation supported by substantial majorities.

What really has to be debated, in all seriousness, is whether the "Republican Form of Government" that some of you are counterposing to my advocacy of greater "democracy" boils down to some version of John C. Calhoun. There is nothing silly about Calhoun's theory. My friend (and fellow Balkinization contributor) Mark Graber often asserts the attractiveness of the Madisonian version of what political scientist Arend Lipjhart has called "consocialitionalism," i.e., the organization of the polity to make sure that it take more than a simple majority to rule. According to Lipjhart, this promotes a valuable spirit of "consensus" (similar to "bipartisanship"). Calhoun's is certainly the most worked-out version of such arguments in American history, though, interestingly enough, there are overtones of such ideas in some of the writings of Lani Guinier on voting design. Indeed, the University of Kansas Press has recently published a new book by James H. Read, Majority Rule versus Consensus: The Political Thought of John C. Calhoun, which I own but have not yet read. The Press usually publishes excellent books, and I have no reason to think that Read's book is an exception.

But my central point is that a Calhounian reading of "republicanism" (putting to one side that Calhoun originally created his theory to defend the interests of slaveowners) puts the lie to any easy notion that the United States is being honest with the rest of the world in pronouncing itself committed to the "democracy project." Not one in 1000 persons, even political sophisticates and political theorists, will associate 21st century "democracy" with Calhoun.

UPDATE: A reader has reminded me that Vermont does not have two Democratic senators inasmuch as Bernie Sanders, a Democratic Socialist, identifies himself as an "Independent" (like Joe Liberman), though he votes with the Democrats on organizing the Senate and the like. So I suppose I should use North Dakota (Kent Conrad and Brian Dorgnan) and Montana (Max Baucus and John Tester) as my examples of two Democratic-senators-states counterbalancing Texas and, say, Tennessee. (Interestingly enough, there aren't any other large states that currently have two Republican senators. The Republican Party has become basically a regional (i.e., Southern) party. Still, the point is that it is a mistake to view Democrats as necessarily the losers in the egregious over-representation of small states. (And, no doubt, the fact that Democrats have half of the senators in the "wheat-belt" states (Kansas, Nebraska, Iowa, and the Dakotas), a majority if one counts Minnesota, helps to explain why it may be impossible to adopt President Obama's sensible proposals to clip the indefensible subsidies that go to agribusiness.)



Comments:

This comment has been removed by the author.
 

Sandy:

What really has to be debated, in all seriousness, is whether the "Republican Form of Government" that some of you are counterposing to my advocacy of greater "democracy" boils down to some version of John C. Calhoun. There is nothing silly about Calhoun's theory. My friend (and fellow Balkinization contributor) Mark Graber often asserts the attractiveness of the Madisonian version of what political scientist Arend Lipjhart has called "consocialitionalism," i.e., the organization of the polity to make sure that it take more than a simple majority to rule. According to Lipjhart, this promotes a valuable spirit of "consensus" (similar to "bipartisanship"). Calhoun's is certainly the most worked-out version of such arguments in American history, though...

I cannot speak for the others, but I have been arguing that the founders intentionally designed our Republic to require a super majority consensus to enact changes and that this is a good thing which saves us from the mischief making of transient simple majorities.

I have some sympathy for the view that the wide discrepancies in state populations represented by our Senators goes beyond the necessities of super majority consensus toward fundamental unfairness.

In your imaginary constitutional convention, allow me to suggest a grand compromise where the Senate is reformed to more closely reflect the population in exchange for a new Article I provision requiring a 60% vote of each chamber of Congress to raise taxes or enter into new debt unless we are in a state of declared war.

This will put some teeth back into the declaration of war clause and stop transient majorities from bankrupting the country as appears to be the current case.
 

... a new Article I provision requiring a 60% vote of each chamber of Congress to raise taxes or enter into new debt...

Yes ... seeing as it worked so well for California, let's see if we can send the whole nation to the precipice.

This will put some teeth back into the declaration of war clause ...

What would put new teeth in the DoW clause is if Congress grew a backbone and impeached any preznit who ignored the Constitution and the laws that Congress duly passed....

Why a 60% vote for budgetary matters would affect that is truly beyond me, though. Particularly when certain preznits kept "wartime" expenses 'off the books'. And who threatened any Congresscritters that didn't fall into line with military budget demands with being branded "surrender monkeys" or even "traitors".

Cheers,
 

arne:

1) California apparently can muster a super majority for fiscal irresponsibility. I have more faith in America as a whole.

2) Under my modest proposal, it does not matter whether a President or a Congress keeps spending on or off the official budget because you need 60% of both chambers of Congress to raise taxes or borrow money to pay for any spending increase on or off budget.
 

First off, one point of me personally is that we live in a republic. It has checks on democratic rule. I doubt you disagree with all of them. So, "democratic" can be tossed around a bit too blithely. Ditto the 17A bit. A regular here gives that too much weight too imho.

Second, actually, I have read a bit of Lani Guinier and her "kids sharing" rule. It seems sensible to me actually.

Calhoun reeks of antebellum, and concern for a certain section. I don't think it really works as a fair application of what some call for today. I say this not as an expert of the guy, though I read some on the era in question.

But, all this concern of hyperpartisanship etc. IS what many today appear to like. Obama is said to be part of that. Some need for compromise etc. Some sort of minority veto, with limits, is inherent in that. Many also think this is important in respect of confirmation of judges.

The protection of minorities etc. is part of our message, including political minorities. A Sen. Byrd is well respected by many libs for some of his comments on executive power, but I guess his respect of the Senate is skipped over.
 

First off, one point of me personally is that we live in a republic. It has checks on democratic rule. I doubt you disagree with all of them. So, "democratic" can be tossed around a bit too blithely. Ditto the 17A bit. A regular here gives that too much weight too imho.

I resemble that remark.

I strongly believe in limitations on strict democracy. The difference I have on the issue of the filibuster is that I want those restrictions to have a solid foundation in either the theory of republican government or the practice. Some of those restrictions have a basis in the Constitution itself: 3 branches of government; presidential veto; two branches of the legislature; and some others. Others, like judicial review, are implicit in the structure of the government and can reasonably be argued to have been intended (see Federalist 78).

Ultimately, though, majority rule is a foundational principle of republican government. If there's going to be an exception to it, there needs to be some justification for it. I don't see that with the filibuster.

I freely admit that a good deal of my antipathy to the filibuster is that I grew up at a time when its principal (maybe only) use was by Southerners to prevent civil rights legislation and defend segregation. I can't see any reason to defend that practice.
 

But, the "theory" of the Senate, the anti-majoritarian aspects inherent in its function and so forth, soon included giving power to individual senators or blocs thereof akin to a filibuster in some form.

Judicial review was opposed by many in the Lochner Era. I don't think the civil rights context is as much of a trump as some think. Especially since many in the North etc. still had to go along. And, when a clear majority existed, the delay was relatively short in the long run.

How does a significant minority have interests protected outside of what can be struck down by judicial review? One person's veto is better in such cases?

If party politics skewered how the Senate was intended to work, e.g., having 45 senators filibuster to challenge it, I think that is the system working as intended more than the alternative.

This doesn't justify the filibuster as now practiced in all the particulars. But nor does mere majority rule across the board in both houses.
 

But, the "theory" of the Senate, the anti-majoritarian aspects inherent in its function and so forth, soon included giving power to individual senators or blocs thereof akin to a filibuster in some form.

I don't get this. The Senate before the Civil War allowed the South to block anti-slavery legislation, but I can't see that as a desireable example. I don't know of any other blocs.

I don't think the civil rights context is as much of a trump as some think. Especially since many in the North etc. still had to go along. And, when a clear majority existed, the delay was relatively short in the long run.

While it's true that many in the North were complicit, the South alone did have the power to block civil rights legislation. It did so for roughly 60 years, starting with anti-lynching legislation around 1905-10 (I'm going off memory) and ending with the Civil Rights Act. Thereafter, civil rights filibusters died out.

How does a significant minority have interests protected outside of what can be struck down by judicial review?

Most recognized rights are protected by the Constitution itself, either in the original document, the Bill of Rights, or the Civil War and other Amendments. To the extent rights have no textual support in the Constitution, enforcing them is problematic in any case.

As for minority interests (I'd hesitate to call them rights), the very structure of the government is designed to provide that protection. That was Madison's whole argument in Federalist 10; it's why legislation has to pass through the hoops of the House, Senate, President, and Court. Adding another hoop to those already created seems problematic to me.

If someone wants to make an exception to such a fundamental republican principle as majority rule, I think that exception should be grounded in one of the following:

1. Theory. I know of no such justification for the filibuster.

2. The general practice of other legislatures. There are lots of legislatures in the world, but I'm not aware of any which allow filibusters. When legislatures in the states depart from majority rule (as, say, CA does with its budget) the results are often disastrous.

3. Historical experience. The principle use of the filibuster in this country until the 1990s was to block civil rights legislation. That's not a promising justification.
 

We grow wheat in Iowa? Must be between the corn stalks.
 

I stand corrected re Iowa. I should have said "corn, wheat, and soy," the principal recipients of agribusiness subsidies.
 

No big deal, but ND's senator is Byron Dorgan (not Brian Dorgnan)
 

Mark and Sandy:

Would you favor a genuine, strict democratic system? I mean one in which all representative seats are based on population and all (non-rights violating) decisions are made by a simple majority? (Maybe something a bit more than 'simple'?)

I'm asking because I am quite torn about such a system. I certainly do not like the filibuster, but I have some worries about the real effects of a more genuinely majoritarian system.

Perhaps I don't trust my fellow citizens or those who typically gain office to represent us. It does seem to me that we often do not have legislation and policies that reflect majority views (viz., abortion rights), and I have the sense that this results from too much pandering to the constituents. In other words, I think the majoritarianism we have tends to be anti-majoritarian, thanks to voting habits, etc.

I have no idea if this makes sense.

Chris, now officially CTS.
 

"puts the lie to any easy notion that the United States is being honest with the rest of the world in pronouncing itself committed to the "democracy project.""

The marvel of our nation has been that we had a constitutionally limited form of government, which helped to keep our rulers from getting into too much mischief. It would be remarkable if said rulers were ever willing to admit that the thing that made us great was that they were in shackles.
 

Would you favor a genuine, strict democratic system? I mean one in which all representative seats are based on population and all (non-rights violating) decisions are made by a simple majority? (Maybe something a bit more than 'simple'?)

Once you make the system representative, you've departed from "direct" democracy (at least in the Athenian sense). Representation is itself a check on the flaws of "direct" democracy.

The basic answer to your question is yes, but I need to do some 'splainin. Of course I think the system should continue to be representative democracy rather than direct. I also favor a two chamber legislature (apportioned by population but chosen differently); a presidential veto (though I'd probably reduce the override to 60% in my Utopia); and judicial review. The Constitution contains other restrictions on democracy (indeed, ANY written constitution restricts pure democracy), and I support those as well.

So... subject to all those exceptions and guards, yes I support simple majority rule.
 

Would people object to a parliamentary house which was not apportioned by population, but by party percentage at the polls? I think this would be vastly more representative of the peoples' interests than overlapping geographically-based districts.

(course, while we're talking utopias, I'd actually replace the House with this parliamentary house, and leave the Senate as is, since the federal nature of our system requires State representation. but that's me. my second best would be to greatly expand the number of representatives, so the Districts are of smaller population. I simply think the country has way too many people now for such a small number of representatives to accurately represent the people. We haven't increased the size of the House since 1913. Our population has tripled since then.)
 

Clocking in at #9, Georgia is probably big enough to qualify as a "big state" with two Republican senators.
 

Just to clarify my last post a bit, I don't mean to endorse every single provision of the Constitution, particularly as currently interpreted. I just can't go through the whole document in a comment so I'm accepting it in general.

my second best would be to greatly expand the number of representatives, so the Districts are of smaller population. I simply think the country has way too many people now for such a small number of representatives to accurately represent the people. We haven't increased the size of the House since 1913. Our population has tripled since then.

I'm somewhat sympathetic to this, though in the long run it's a hopeless task. There's a line somewhere in which the size of the legislative body makes it unworkable. I don't pretend to know where to draw that line, though I assume the House of Commons would be at the upper end of the scale. Whatever we do, though, the rise in population will undo it faster than we can adjust.
 

Mark: Thanks. I really did not think you were in favor of Athenian style direct democracy. (Nightmarish, to a philosopher.)

I'm flu addled, so please bear with me. I guess I would be happy with a more genuine democracy if there were some way to make the reps really legislate according the majority views of the people. But, the only way I can see this working is by requiring the people to vote, which goes against another grain, and really getting the lobby money out of the pipeline.

I've also long been interested in the kind of parliamentary scheme Nerpzillicus mentions. Here, too, I have worries. I look at Israel and think they are in a worse mess than we are with our 2 parties and filibustering. But, I assume a parliamentary system might be less susceptible to the effects of gerrymandering of districts?

(Chris)
P.S. Is it me, or is that a pretty rough crowd over at Volokh?
 

As to Mark Field's latest reply to me personally:

(1) You support checks that are "implicit in the structure of the government" -- I think implicit in the Senate is some form of filibuster function. By design, it is anti-democratic, and simple majority would negate part of its reason for being. The filibuster grew early as an aspect of this.

(2) The South wanted things too. If the North acted to block such power, including by presidential action (e.g., desegregation of the armed forces ... filibustered?), it could have led to different results. But, simply put, the North didn't care enough and large parts were just as racist. When the N. did care enough, the South could not stop civil rights law.

(3) First, property rights (and some other areas) that now are left to the political processes were originally thought of as minority rights too by Madison et. al.

Second, yes, and the Senate was intended to be anti-majoritarian, and not just follow majoritarian party politics of today. This is the principle you don't see.

If a majority alone will decide things, the Senate loses a key aspect of it character. This includes the "historical" character you also cite. As Sen. Byrd says most famously, the power of the minority has been a force here.

A senator is concerned with a nominated judge that would serve his/her state. They historically were seen as particularly concerned about such people. If they had a problem, senatorial courtesy would justify delay or even refusal. This is what if not a sort of filibuster?

Filibuster power in all its forms simply is not just about civil rights legislation.
 

I assume a parliamentary system might be less susceptible to the effects of gerrymandering of districts?

I don't know how other countries apportion their legislatures. We do need to solve the gerrymandering problem because it undercuts the legitimacy of the whole system.

Is it me, or is that a pretty rough crowd over at Volokh?

Heh, it can be. OTOH, I've been practicing law for 30 years and I'm pretty used to people on the other side saying nasty things. I stopped letting it bother me and I try to respond to those worth responding to. One of the good aspects of the internet is that, unlike private conversation, you can simply ignore a comment.

I think implicit in the Senate is some form of filibuster function. By design, it is anti-democratic, and simple majority would negate part of its reason for being.

If you mean that the Senate is malapportioned, then I agree. Frankly, the filibuster bothers me a lot less as long as that persists.

However, if you mean more than that I disagree pretty strongly. The fact that we accept one departure from democracy doesn't mean we must accept others. At some point that logic would eliminate democracy entirely. As I noted above, we have a lot of restrictions on majority rule now; I don't think eliminating the least defensible will result in tyranny.

Nor do I see the Senate as counter-majoritarian in any other sense. The Founders clearly expected that the basic rule of operation in our government would be by majority rule. Here are some examples:

George Washington, Message to the Third Congress, November 19, 1794 (discussing the Whiskey Rebellion): “to yield to the treasonable fury of so small a portion of the United States would be to violate the fundamental principle of our Constitution, which enjoins that the will of the majority shall prevail.”

Thomas Jefferson, First Inaugural Address (March 4, 1801): “[I]t is proper you should understand what I deem the essential principles of our Government.... absolute acquiescence in the decisions of the majority, the vital principle of republics....”

In Federalist 58, James Madison responded to an anti-Federalist argument that the quorum in the House of Representatives ought to be more than a majority. In fact, this anti-Federalist argued, the Constitution should have required more than a majority for certain votes (IOW he wanted to Constitutionalize the filibuster). Madison rejected these arguments as leading to minority rule, a rule inconsistent with fundamental republican principle:

“It has been said that more than a majority ought to have been required for a quorum; and in particular cases, if not in all, more than a majority of a quorum for a decision. That some advantages might have resulted from such a precaution cannot be denied. It might have been an additional shield to some particular interests, and another obstacle generally to hasty and partial measures. But these considerations are outweighed by the inconveniences in the opposite scale.

In all cases where justice or the general good might require new laws to be passed, or active measures to be pursued, the fundamental principle of free government would be reversed. It would be no longer the majority that would rule: the power would be transferred to the minority.”

Similarly, Alexander Hamilton criticized the Articles of Confederation (Federalist 22) precisely because they required more than a majority vote (2/3 in most cases, unanimity in some): “Its operation contradicts the fundamental maxim of republican government, which requires that the sense of the majority should prevail. … To give a minority a negative upon the majority (which is always the case where more than a majority is requisite to a decision) is, in its tendency, to subject the sense of the greater number to that of the lesser. … The public business must, in some way or other, go forward. If a pertinacious minority can control the opinion of a majority respecting the best mode of conducting it, the majority, in order that something may be done, must conform to the views of the minority; and thus the sense of the smaller number will overrule that of the greater….”

Finally, Abraham Lincoln, facing the greatest challenge to the principle of majority rule ever seen in this country, a challenge which called into question the very ability of republican government to survive at all, echoed Madison when he pointed out the alternatives to majority rule in his First Inaugural:

“A majority held in restraint by constitutional checks and limitations, and always changing easily with deliberate changes of popular opinions and sentiments, is the only true sovereign of a free people. Whoever rejects it does of necessity fly to anarchy or to despotism. Unanimity is impossible. The rule of a minority, as a permanent arrangement, is wholly inadmissible; so that, rejecting the majority principle, anarchy or despotism in some form is all that is left.”

As I said above, I need a good reason to place a limit on the principle of majority rule which (1) adds to those already existing; (2) has no textual support in the Constitution (and some textual opposition -- the tie breaker clause); (3) is followed by no other legislature in the world; (4) and has no historical support as essential to liberty (and a good deal of history as obstructive to liberty).

A senator is concerned with a nominated judge that would serve his/her state. They historically were seen as particularly concerned about such people. If they had a problem, senatorial courtesy would justify delay or even refusal. This is what if not a sort of filibuster?

I don't see that Senators have any more interest in this than House members do. The reason they can block an appointment is simple -- the advise and consent clause. But there's no greater intrinsic interest.

In any case, I oppose Senatorial "holds" too.
 

The problem with simple majority rule not subject to checks and balances is that a narrow majority soon learns that it can take the money of electoral minorities for itself and limit the liberties of minorities for its own benefit.

The benefit of requiring a supermajority consensus is that the electoral minority has more of a voice in the uses of government police power and the burdens of government are more likely to be avoided or spread more fairly.
 

Former VP "Dick Chency"? Surely you mean Dick Untracy?
 

Wow, when you try to act like an all-knowing intellectual, you might want to proofread - "Dick Chency"??? you liberal elitests always give me a good laugh
 

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Asbestos was known in antiquity, but it wasn't mined and widely used commercially until the late 1800s. Its use greatly increased during World War II Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with
asbestos exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of
asbestos exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams. By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for
mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exist at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with
asbestos wear personal protective equipment to lower their risk of exposure. Recent findings have shown that a mineral called erionite has been known to cause genetically pre-dispositioned individuals to have malignant mesothelioma rates much higher than those not pre-dispositioned genetically. A study in Cappadocia, Turkey has shown that 3 villiages in Turkey have death rates of 51% attributed to erionite related
mesotheliomaExposure to
asbestos fibres has been recognised as an occupational health hazard since the early 1900s. Several epidemiological studies have associated exposure to asbestos with the development of lesions such as asbestos bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and peritoneum.
The documented presence of
asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to
asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure.
Commercial
asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia.
Family members and others living with
asbestos workers have an increased risk of developing
mesothelioma and possibly other asbestos related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to asbestosMany building materials used in both public and domestic premises prior to the banning of
asbestos may contain
asbestos Those performing renovation works or activities may expose themselves to asbestos dust. In the UK use of Chrysotile asbestos was banned at the end of 1999. Brown and blue
asbestos was banned in the UK around 1985. Buildings built or renovated prior to these dates may contain asbestos materials.
For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given simultaneously with chemotherapy. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in selected patient populations with some patients surviving more than 5 years. As part of a curative approach to
mesothelioma radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although
mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiation Therapy when given alone with curative intent has never been shown to improve survival from
mesothelioma The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.
Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive "curative" surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural
mesothelioma showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.
Cisplatin in combination with raltitrexed has shown an improvement in survival similar to that reported for pemetrexed in combination with cisplatin, but raltitrexed is no longer commercially available for this indication. For patients unable to tolerate pemetrexed, cisplatin in combination with gemcitabine or vinorelbine is an alternative, although a survival benefit has not been shown for these drugs. For patients in whom cisplatin cannot be used, carboplatin can be substituted but non-randomised data have shown lower response rates and high rates of haematological toxicity for carboplatin-based combinations, albeit with similar survival figures to patients receiving cisplatin.
In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage I or II Mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer.
mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects. Indeed, this trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumor mass combined with minimal side effects.
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by at the Washington Cancer Institute. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.
This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.

What is the mesothelium?
The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs to glide easily against adjacent structures.
The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The
mesothelioma tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
What is mesothelioma?
mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs.
cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.
How common is mesothelioma?
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.
What are the risk factors for mesothelioma?
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to
Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person's risk of developing cancer of the air passageways in the lung.
Who is at increased risk for developing mesothelioma?
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
The risk o f asbestosrelated disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.
There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to
asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
What are the symptoms of mesothelioma?
Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to
asbestos Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis
How is
mesotheliomadiagnosed?
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.
A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the
cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the
cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.
Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
How is
mesotheliomatreated?
Treatment for mesothelioma depends on the location of the
cancerthe stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.
Surgery is a common treatment for
mesotheliomaThe doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural
mesotheliomaa lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
Stereo Tactic Radiation Therapy also called radiotherapy, involves the use of high-energy rays to kill
cancercells and shrink tumors Radiation therapy affects the
cancercells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the
cancercells are found (internal radiation therapy).
Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat
mesotheliomaare given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).
To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation Therapy and surgery may also be helpful in relieving symptoms.
 

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