Friday, March 30, 2012
Public health for nincompoops
Consistency, it is said, is the mark of a true champion. Utter lack of consistency, therefore, must indicate something else entirely. I'll be kind and call it: nincompoopery.
When it comes to public health policy, we are a pack of utter nincompoops. Sorry, but it is what it is.
The timing of this rant is inspired by recent events related to women and matters of family planning. We'll come back to that. For now, let's try this on:
Should medical marijuana be legal everywhere, or not?
You likely had a knee-jerk reaction to the marijuana question. You may feel strongly that marijuana should absolutely be available for medical use. You may feel just as strongly that the idea is outrageous. It's an illegal drug, after all. Or you may feel you don't know enough about medical marijuana to decide.
But I think the best response to the question is another question, a deeper question, a question that gets at the principles--the first principles--that most reasonable people would agree should decide the matter: On what basis is ANY substance approved or disapproved for medical use?
Let's at least agree that trying to answer this about a drug, and never bothering to answer it about all drugs, is inordinately inefficient. It means starting the same debate from scratch every time. Truly silly at best, a formula for inconsistent idiocy at worst. Nincompoopery.
So, on what basis SHOULD any drug be approved or disapproved?
We might think a drug should be disapproved if it's dangerous. But that's clearly not so; drugs far more dangerous than marijuana are used in medicine all the time. A few that spring immediately to mind include nitroprusside, Ketamine, Coumadin and haloperidol.
Perhaps a drug should be disapproved if it's addictive? That's clearly not the case either, since vastly more addictive drugs than marijuana are in routine use, among them the benzodiazepine class of sedatives, home to Valium, that are among the very few habit-forming drugs from which withdrawal can actually be lethal. But then again, alcohol is also potentially habit-forming, and withdrawal can be lethal, and not only is it approved for use, but no prescription is required. And while on the topic, plain old tobacco is more addictive than cannabis.
Well, all right. Perhaps a drug should be disapproved if it's already disapproved! Perhaps we should simply hold the line against medical use of substances that are already illegal. That would be enough to dispatch marijuana.
But it would also be enough to dispatch cocaine and heroin, and here I've got bad news. Cocaine is an approved drug, on hand in virtually every emergency department in the country. It is used, among other things, to control epistaxis, the medial term for severe nosebleeds. During my years as an ER doc, I treated patients with it on a number of occasions. We would soak cotton in a cocaine solution, and into the patient's nose it would go.
As for heroin, it's not legal per se, but Dilaudid is. This is a synthetic opiate painkiller that is, in essence, heroin on steroids. It is many times more potent than heroin or morphine in its narcotic effects.
We could, I think, come up with sound criteria to guide decisions regarding all drugs. They would include such things as: a clear need, clear results of testing, a favorable benefit/risk ratio when used as intended and so on. For what it's worth, medical marijuana almost certainly passes through any such filter, but that's a topic for another time.
What about medically-assisted dying? This is another emotive, provocative topic prone to evoke reflexive answers, but not a lot of reflection. If the goal of medical treatment is to extend life at all costs, the topic is clearly taboo. But then the right question is: What is the goal of medical treatment?
Personally, I think medical treatment is about the patient. I think it serves the patient of sound mind, and the family of sound heart. Admittedly, soundness of mind and heart can at times be hard to judge, but more often than not we can make the call. But this, too, is a debate for another day. My point now is simply that judgments about medically-assisted dying in the absence of judgments about the fundamental objectives of medical care are cart before horse, and tail wagging the dog.
Not to mention (come to think of it, yes to mention) the fact that those elements in our society most opposed to assisted dying seem often to be OK with capital punishment. So sanctity-of-life arguments don't seem to put the issue to bed.
Perhaps we want to oppose all societal actions that aid and abet misguided or objectionable behavior? That is the customary opposition to so-called "harm reduction" strategies, such as needle exchange programs for IV drug users. Such programs have been shown, decisively, to reduce HIV transmission without increasing drug use, but there is a prevailing objection on principle.
But is it a "first" principle, applied consistently? I dare say not! Seat belts and air bags prevent injuries and deaths from car crashes that overwhelmingly would not occur in the first place if people didn't drive while impaired, drive while distracted, drive while texting or exceed the speed limit. So don't seat belts and air bags "aid and abet" speeding, driving under the influence and so on? I leave you to chew on it.
I take a lot of abuse from the "Stop telling us what to do, Katz!" crowd. It doesn't cost me any sleep; it's all part of the gig. But I note it as a fact.
But here's the thing: Those who call me names, many nasty and some profane, for suggesting that we at times need public health policies to protect us--that, at times, the best defense of the human body resides with the body politic--do so on the grounds of defending autonomy. They do so arguing that self-sufficient, self-reliant, reasonably intelligent adults don't need the likes of me, or a big government, telling them what to do.
I might just take this on the chin and live with it (although a counter-argument is not hard to make), were it even remotely consistent. But it's not.
As best I can tell, it's the same "Butt out and let autonomous adults run their own lives" crowd who feels that they/the government absolutely SHOULD tell women when they can and can't get contraceptives, and when they must have ultrasound probes rubbed over them, and perhaps even inserted into them.
In other words, somewhere out there is a pack of hypocritical, occasionally foul-mouthed nincompoops who do NOT object to autonomous adults being bossed around. They simply want to be the ones to do the bossing!
For what it's worth, I think there is a middle path best defined by first principles. I think we could sensibly decide when drugs should be legal or illegal, available by prescription or over the counter. I think we could sensibly decide when regulations are required, and when informing people is enough because knowledge is power. I think we could, but for the most part, we don't.
We hide behind ideology while ignoring epidemiology, and let tales of sound and fury signifying nothing consistent or even sensible wag the dogma.
What we wind up with is public health policy for nincompoops. And if this morass of sloppy thinking and hypocrisy is the best we can do, that's about what we deserve.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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