The Freedom Bulletin

Check out this piece in the Wall Street Journal by Pamela Hartzband and Jerome Groopman about how our society relies too much on the judgment of medical “experts” instead of trusting individuals to make their own medical decisions:

 ”Should everyone take vitamin D, and if so, how much? At what age and how often should a woman have a mammogram? Should a healthy man be screened for prostate cancer, and if cancer is diagnosed, how should he be treated? …

Democrats and Republicans share a fundamental misconception about medical care. Both assume that, as in mathematics, there is a single right answer for every health problem.”

As described in the article, people vary in whether they are “minimalists” or “maximalists” about the amount of medical procedures they prefer to undergo, as well as whether they are “believers” or “doubters” about the effectiveness of medical treatments. For example, the U.S. Preventive Services Task Force, which recently lowered the recommended frequency of mammograms, pap smears, and prostate cancer screenings, is described as having a “minimalist” and “doubter” outlook. (In my opinion, today’s society has a definite bias towards the maximalist point of view; these recommendations are actually maximalist compared to what I would choose.)

People have different preferences in other ways too. Some are more disturbed than others about the prospect of gruesome things, such as surgery, being done to their bodies. Some people would rather wait to do a medical procedure, while others prefer to get it over with. Some people are modest and prefer not to undergo medical procedures that involve removing clothing, while other people do not care about this.

All of these preferences are equally valid. Policy makers and doctors too often ignore this, acting as if any view other than the one currently favored by the medical establishment must be based on ignorance, laziness, or irrationality. But as Hartzband and Groopman write:

“Patients and doctors can differ with experts and not be ignorant or irrational. Policy makers need to abandon the idea that experts know what is best. In medical care, the ‘right’ clinical decisions turn out to be those that are based on a patient’s goals and values.”

Read the full article at the Wall Street Journal.

An article in Nature (original source with paywall here) claims that sugar should be regulated like alcohol and tobacco through taxes and age restrictions because it is equally “toxic” to people. According to CBS News:

“The United Nations announced in September that chronic diseases like heart disease, cancer, and diabetes contribute to 35 million deaths worldwide each year, according to the commentary. The U.N. pegged tobacco, alcohol, and diet as big risk factors that contributed to this death rate.

Two of those are regulated by governments, ‘leaving one of the primary culprits behind this worldwide health crisis unchecked,’ the authors, Robert H. Lustig, Laura A. Schmidt and Claire D. Brindis, argued.”

If sugar was something inflicted on people against their will, like pollutants in the air, then it would make sense to regulate it. But sugar is something that people can choose to eat, or not to eat. Consuming lots of sugar, just like consuming lots of alcohol or tobacco, may very well increase the risk of dying of heart disease, cancer, or diabetes. But “experts” have no right to assume that it would be beneficial for these risks to be lowered no matter the cost. Each person is the ultimate expert in his or her own well-being, and each person will arrive at a different conclusion when it comes to balancing health and quantity of life with enjoyment and quality of life. It’s not a bad thing for decisions about what to consume to be “unchecked,” as the authors of the article characterize it; it’s a basic part of a free society.

Sugar, alcohol, and tobacco do have some similarities. Sure, they all can have negative health effects. But choosing to consume them does not interfere with anyone else’s life; therefore people have a fundamental right to consume as much or as little as they choose. Instead of considering the similarities a reason to regulate sugar, why not consider de-regulating tobacco and alcohol?

The Boston Globe‘s Jeff Jacoby had a great column today about the recent federal court decision halting, temporarily at least, the FDA’s requirement that all cigarette packages display graphic, paternalistic warnings urging people to stop smoking:

The FDA’s gruesome new labels are not designed to provide consumers with useful information about the hazards of smoking. After 45 years of mandatory Surgeon General’s warnings, every non-comatose American knows perfectly well that cigarettes are a noxious health risk. That’s why the share of Americans who smoke at least occasionally has fallen to an all-time low of 19.3 percent, or less than 1 in 5 — a far cry from the more than 42 percent who were smokers in 1965. No one, not even Big Tobacco, disputes Washington’s right to require cigarette makers to disclose pertinent facts about their product’s dangers. Those disclosures, it’s clear, have been effective.

So why the shrill new labels? Not to inform Americans, but to indoctrinate them. To “grab people by the lapels,” as NPR put it last summer, “and be the visual equivalent of someone yelling: ‘Stop smoking!’”

I couldn’t have said it better than he did. Read it at BostonGlobe.com.

As almost the whole world knows, Dr. Conrad Murray was convicted on Monday of involuntary manslaughter for giving Michael Jackson a dose of propofol that ultimately caused his death. After thinking about this for a couple of days, I don’t think this was the right verdict.

In court, the case came down to how exactly Jackson received the fatal dose. Prosecutors claimed that Murray administered the propofol to Jackson, while the defense claimed Jackson injected it himself. But neither side denied that Jackson wanted and asked for the anesthetic. According to Murray, “He was pleading and begging to please please let him have some milk because that was the only thing that would work.”

So basically, Murray did what Jackson asked for. Jackson weighed the risks and the benefits of taking propofol in a home setting to help him sleep, and decided that the benefits outweighed the risks. Yes, this is a dangerous thing to do, and many people would consider it stupid, but people have the right to do dangerous things if they want to, and doctors have the right to help them carry out their decisions. Manslaughter convictions should be reserved for those who cause people’s deaths against their will. Although Jackson’s family members, friends, and fans are understandably upset at his death, and want to see someone punished, the truth is that Jackson died as a result of his own choices (choices he had a right to make). Convicting Murray of manslaughter is not justice.

Murray is appealing his conviction. It’ll be interesting to see how the appeal goes.

There’s a debate going on in Massachusetts about whether written permission should be required for HIV testing or just verbal consent to medical treatment in general. Currently MA is one of only two states that require written consent, and groups who want to encourage more testing are trying to change this. Personally I don’t really care whether consent is verbal or written, but I think there need to be stronger, not weaker, consent requirements for all medical procedures.

We live in a system where, when someone goes into a doctor’s office, the doctor usually just tells them what medical tests they are going to have, maybe asking, as an afterthought, if that’s OK. This is wrong. As I explained in a blog post from yesterday, this is not true consent. Many people, especially if they are shy by temperament, find it difficult or impossible to refuse what a doctor tells them to do. We need a system where the patient, not the doctor, is in charge of medical decisions. Instead of saying what medical procedures are needed, doctors should tell people what services they offer (perhaps through a brochure, sheet of paper, or sign) and the person can indicate which services they would like, with advice from the doctor only if asked.

Another part of the proposed law would require doctors’ offices to have written permission before sharing a customer’s HIV status. This seems pretty reasonable. People should be in control of their own medical records, and it should be a no-brainer that doctors should not share information without the permission of the person the information is about. But of course, doctors had paternalistic and pompous things to say in opposition to the law:

Dr. Howard Heller…said the legislation would mean that each time he referred an HIV patient to a different specialist outside of his organization, he could not tell that provider about any HIV-related medications that patient was taking, without first getting the patient’s written permission.

And that’s a problem why?

“Each time we share information we would have to have written informed consent…and each step we put in the way puts more impediments to getting tested,” said Dr. Stephen Boswell.

That’s right, how dare the wishes of the people he is supposed to be serving get in the way of making them to do what he wants? I know doctors are trying to make people healthier, but too many of them have lost sight of the idea of liberty and the dignity of individuals. Doctors need to give up their paternalistic attitudes and start treating their customers with respect, just as members of any other profession would. They need to focus less on what they think is best for their patients and more on their patients’ wishes.

Remember when the FDA decided to require all cigarette packages to display graphic warning labels? Five tobacco companies  - R.J. Reynolds, Lorillard, Commonwealth Brands, Ligget Group, and Santa Fe Natural Tobacco Co – are suing in federal court to stop this. Although tobacco companies are far from sympathy-evoking, and although they are almost certainly motivated at least in part by financial gain in this lawsuit, the fact is that they are right. These warning labels are paternalistic and are an affront to individual liberty.

The lawsuit reads,

“Never before in the United States have producers of a lawful product been required to use their own packaging and advertising to convey an emotionally-charged government message urging adult consumers to shun their products.”

It continues,

“This is precisely the type of compelled speech the 1st Amendment prohibits.”

I couldn’t have said it better myself. Manufacturers should not be allowed to put lies or deceptive statements on packages. It even makes sense to require companies to provide factual information about their products, such as ingredients, risks, and benefits, on packages. But these labels – graphic pictures of diseased lungs, caskets, and dead bodies – go far beyond providing information. They are propaganda designed to disgust people and make them avoid smoking. They are also paternalistic because by requiring them, the FDA has decided against giving people the facts and allowing them to make their own decisions, and decided instead that people should be emotionally manipulated into doing what the FDA thinks is best for them.

It would be bad enough if the FDA displayed this insulting propaganda on government property or purchased advertisements with its own resources. But the new policy requires private companies – in fact the very companies that the warnings are targeted against – to use their resources to display the FDA’s propaganda. Requiring cigarette companies to speak the government’s message – an insulting, paternalistic, and anti-liberty message at that – is a violation of free speech rights.

Last week, Paul Krugman wrote in the New York Times that “patients are not consumers.” He asks,

“Here’s my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as ‘consumers’? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car — and their only complaint is that it isn’t commercial enough.”

My question is, how did it become acceptable to refer to people who receive health services as “patients” and to refer to the services themselves as “care”? Why did society decide to think and speak about health services as if they are fundamentally different from other goods?

I’m assuming that if Krugman objects to health services being treated the same as other services and products, he must be in favor of the prevailing system, in which people are widely presumed to be incapable of making decisions about their health and are expected to obey whatever doctors tell them to do. But this paternalistic view deprives people of dignity and freedom.

Krugman gives the following reasons for his view:

“Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.”

Perhaps medicine is an area where decisions tend to have weighty consequences and professionals tend to have extensive training. But this doesn’t make it fundamentally different from other professions. Chefs, photographers, interior designers, personal shoppers, and investment bankers all have training and expertise, and their work affects people’s well-being to various degrees, but people who use their services are still considered consumers, and it is also considered perfectly acceptable, by the law and society, for people to cook their own food, take their own photos, decorate their own houses, buy their own clothes, and invest their own money.

In all areas, people should have the right to make any decision they want, as long as it does not violate the rights of anyone else. This includes making decisions that are risky, unwise, or based on non-expert knowledge. I think that ordinary people are more capable of making medical decisions than Krugman gives them credit for – almost anyone can read about the benefits and risks of a medicine or procedure and decide whether they want it or not. But even if specialized knowledge is required to make certain decisions “intelligently,” people have a right to make unintelligent decisions. For situations where a person is incapacitated, we could create a system in which people can easily register their medical preferences ahead of time and know that they will be respected. Even when a person “needs” medical attention immediately, they should still be free to take as long as they want to decide (even if this is unhealthy), to make a quick decision themselves (even if it may be the wrong one), or defer to a doctor’s judgment if they so choose. And severe stress is certainly no reason for people to be unable to make their own decisions.

“The idea that all this can be reduced to money — that doctors are just ‘providers’ selling services to health care ‘consumers’ — is, well, sickening,” Krugman writes. No, the idea of doctors and their customers as equals, engaging in voluntary transactions, is beautiful. What is truly sickening is a society and legal system that considers it inappropriate for people to make decisions about their own bodies. Any change toward viewing people who receive health services as consumers is a good change, which the world desperately needs more of.