Crazy Doctor Sangrado

One of the amusing episodes in Gil Blas concerns a charlatan doctor named Sangrado. When he sees a patient with gout and learns that the patient regularly eats large meals consisting mostly of meat and drinks large quantities of wine, he suggests that the patient’s diet may be aggravating his gout. He advises him to eat moderate meals consisting mostly of vegetables, legumes and baked apples, and says he should drink water instead of wine. In fact, the physician believes that everyone should follow this diet.  He doesn’t agree with the prevalent belief that wine is necessary to prevent indigestion, and he thinks people should stop eating before they are stuffed, even if they can afford to eat more.

This doctor is portrayed as a fool who kills his patients and makes Gil Blas sick through denying him wine. Isn’t it funny how medical advice which now is now so mainstream that it seems obvious was in the past seen as self-evident lunacy?

 Of course, Sangrado also says that no one really needs blood to live, and advises the patient to have himself bled as often as possible.

Graphic labels on cigarettes packages

Forcing cigarette companies to put graphic warning labels, including health warnings, pictures of diseased organs, and the 1-800-QUIT-NOW number, on cigarette packages, is a violation of the First Amendment, according to a recent and totally correct ruling by the DC Circuit (pdf).

You might wonder why this is so, since cigarette companies are already required to put warning labels on packs, while alcohol manufacturers have other warning labels, and all makers of packaged food are required to list ingredients, calories and so forth. The legal reasoning behind this regulation is that the government had a legitimate interest in making sure that consumers are accurately informed about the contents and risks of the food, beverages and cigarettes they consume.

Now, there is nothing in the Constitution restricting the ability of government agencies to campaign against smoking, taking the public stand that the risks of smoking outweigh its benefits. The libertarians among us might think that this is not a proper use of the power and money of the state, but the libertarians among us are often disappointed. However, the state still does not have the right to force any individual or company to express a certain opinion. The federal district court and DC Circuit agree that graphic labels and the QUIT NOW message go beyond informing consumers about health risks and amount to discouraging smoking. (In fact, the FDA made no secret of the fact that it hoped the labels would nudge people to quit.) This "ideological" message is one the government cannot force a company to send.

The Companies contend that, to the extent the graphic warnings go beyond the textual warnings to shame and repulse smokers and denigrate smoking as an antisocial act, the message is ideological and not informational. “[B]y effectively shouting well-understood information to consumers,” they explain, “FDA is communicating an ideological message, a point of view on how people should live their lives: that the risks from smoking outweigh the pleasure that smokers derive from it, and that smokers make bad personal decisions, and should stop smoking.”

No one doubts the government can promote smoking cessation programs; can use shock, shame, and moral opprobrium to discourage people from becoming smokers; and can use its taxing and regulatory authority to make smoking economically prohibitive and socially onerous. And the government can certainly require that consumers be fully informed about the dangers of hazardous products. But this case raises novel questions about the scope of the government’s authority to force the manufacturer of a product to go beyond making purely factual and accurate commercial disclosures and undermine its own economic interest—in this case, by making “every single pack of cigarettes in the country [a] mini billboard” for the government’s anti-smoking message.

The so-called "warning labels" are not really warning at all, the Court held, but propaganda. Some convey no relevant facts, and others might be deceptive: an image of someone smoking through a tracheotomy hole might give the inaccurate impression that a tracheotomy is a common result of smoking.

Many of the images do not convey any warning information at all, much less make an “accurate statement” about cigarettes. For example, the images of a woman crying, a small child, and the man wearing a T-shirt emblazoned with the words “I QUIT” do not offer any information about the health effects of smoking. And the “1-800-QUIT-NOW” number, when presented without any explanation about the services provided on the hotline, hardly sounds like an unbiased source of information. These inflammatory images and the provocatively-named hotline cannot rationally be viewed as pure attempts to convey information to consumers. They are unabashed attempts to evoke emotion (and perhaps embarrassment) and browbeat consumers into quitting.

I find myself saying, as often before, thank God for the First Amendment. Cigarette companies in other countries are already forced to use graphic "warning" labels. Now, if only we still had the Fourth, Fifth and Sixth Amendments...

Fat and class

The fact that the people at the gym are thin and the people at Walmart are fat does not show that going to the gym makes people thin or that Walmart makes people fat.

Poor people in America are fat and rich people are thin. The disgust the thin upper classes feel for the fat lower classes has nothing to do with mortality statistics, and everything to do with feelings of moral superiority engendered in thin people by the sight of fat people. Precisely because Americans are so repressed about class issues, the disgust the (relatively) poor engender in the (relatively) rich must be projected onto some other distinguishing characteristic. In 1853, an upper-class Englishman could be quite unself-conscious about the fact that the mere sight of the urban proletariat disgusted him. In 2003, any upper-class white American liberal would be horrified to imagine that the sight of, say, a lower-class Mexican-American woman going into a Walmart might somehow elicit feelings of disgust in his otherwise property sensitized soul. But the sight of a fat woman—make that an “obese” woman, better yet a “morbidly obese” woman going into Walmart, ah, that is something else again…the fact that this woman happens to be poor and non-white can be dismissed by those observers as an irrelevant coincidence.

--Paul Campos

Buying healthcare is hard

I've been calling doctor's offices trying to find out the price for some relatively simple and common procedures. It's ridiculously difficult. For every three receptionists I talk to, one will act as if she has no idea what a price estimate even is. She'll offer me medical codes, but dollar amounts? You must be crazy.

Another will assume I must be uninsured, because why else would I care about the price? She'll tell me that actually they charge more for cash patients. Yes, thank you, for making it clear that you practice price discrimination which hurts the most disadvantaged patients.

Probably two will require me to laboriously explain that yes, I know the price I pay may not be the same as what they charge the insurance company.

Oh, and those price comparisons?

Procedure 1:
One office told me it would be $ 20-500 --and they refused to narrow it down any more than that.
Procedure 2:
At one office it was $70, at another $470.
Procedure 3:
I called three offices: one said $800, one $1200, and one $300. The one my primary care physician recommended was the most expensive.

I think this tells us something about why our healthcare system doesn't work.

Transsexuals

Fact is, most transsexuals agree there’s something wrong with them. The difference is they think it’s with their bodies, while unsympathetic outsiders say it’s with their heads.

Are transsexuals mentally ill? Pretty meaningless question, since there is no objective definition of mental illness. In a remarkably calm and even-handed column on a contentious topic, the author of the Straight Dope suggests that a condition which causes unhappiness in itself, rather than unhappiness as a result of social disapproval, should be considered a mental illness:

DSM-III dropped the old classification of homosexuality as a disorder because of the dawning realization that whatever gays and lesbians might be unhappy about, it wasn’t about being gay or lesbian as such — the main issue was social disapproval. In contrast, even with all the social acceptance in the world, transsexuals are still going to think they’re the wrong sex.

What ought to be measured, but has not yet been with sufficient validity, is whether sex reassignment surgery makes transsexuals happier (ideally I would think the surgery group should be compared, not only to a control group, but to a group of transsexuals getting cognitive-behavioral therapy intended to help them learn to get away from the obsessive thought of being in the wrong body.)

I know there's a certain amount of controversy over terminology here, but I don't care enough to figure out whether "transsexual" is considered the correct term. 

 

 
I highly doubt whether many people would even notice a transsexual in the locker room. But it would provide a great opportunity for unscrupulous men, wouldn't it?

I have not yet seen an explanation for why there seem to be so many more male-to-female transsexuals than the other way around. Is it because it's easier for women to wear male clothing without automatically being read as transsexual, so that they can indulge their genderbending urges without having to go all the way? Or is it that women are lower-status in our culture, so that pretending to be a male when you're not doesn't have the same transgressive edge as pretending to be female?

If you buy into the PC theories about transsexuality, you'd have to say that actually there are just as many female-to-male as the other kind, but for some reason they are not as willing to be open about it.

You probably won’t get AIDS

"If you look at the data we have right now, it is very clear what is driving the AIDS epidemic in the United States. It's not sustained heterosexual transmission, it is not IV drug use, it's basically in African American men who have sex with men. HIV in heterosexuals persists only because you have inflow either from other countries, from high prevalence areas for example, or from other risk groups such as intravenous drug users or men who have sex with men."

Defining disease

A Slate article on the prevalence of medical overdiagnosis is mostly skippable summary of what we already know. The interesting part comes near the end:

Many critics of modern medical care see overdiagnosis everywhere they look and don't reliably separate the wheat from the chaff. They derisively state that coughing children are too often labeled asthmatic; "twitchy legs" and "impaired sex drive" are inexplicably considered medical problems; those who can't read are for some reason called dyslexic; those who are just sad are instead said to be depressed; and people with joint pain are termed arthritic. The subtext of their comments is, There's nothing wrong with these people. Yet they're still patients who can't sleep, breathe, read, or enjoy sexual relations. They seek help, and it's wrong to ignore them...let's not blame people with dyslexia, erectile dysfunction, or restless leg syndrome for the mess.

Here are the errors. First, the assumption that anything which can be given a fancy name is a disease. Remember that "erectile dysfunction" has only been a disease since Viagra was invented. Before that, men dealt with their psychological problems through psychological means. It's nice that we have drugs now, but they shouldn't be portrayed as the only way to solve a person's problems.

Second, the idea that people who are suffering should be helped does not imply that 'we' (doctors, health insurance companies) should help them. But of course if we were to admit that these conditions are largely within the patients' power to change, we would have to give up our power over them and our ability to define them as 'patients'.

Third, the idea that denying 'disease' status to these conditions amounts to 'blaming' people who suffer from them. Because a person who 'has a disease' deserves our pity and forbearance, while a person who has a simple psychological problem doesn't. This way of thinking is why people like gathering meaningless diagnoses in both the medical and psychological fields. 'Having a disease' allows them to deny their own responsibility for their lives.

Fourth, the error of believing that every problem needs to be solved. It's not okay for people to have flaws and weaknesses; people should be equal, with no personality differences; if some people are bad at reading, they have a disease which needs to be cured. If some people are sad, they need to be argued or drugged out of it.

All common themes in modern medical discourse. All wrong.