American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, February 28, 2013

All the wrong questions

Should marijuana be legal, for either medical or recreational use? I think the best initial answer to this is: It's a crummy question! We are good at those.

It's a crummy question, because it calls for answers based on unsubstantiated opinion. Answering it does not invoke or even encourage any relevant evidence, or precedent. So what would a better question be? How about: On what basis should any particular substance be legal for either medical or recreational use?

There are many advantages to this new question. For one thing, since it has no emotionally-charged word like "marijuana" in it, it avoids provocation. It invites thought, rather than potentially thoughtless passion, the proverbial knee-jerk response. For another, it almost requires consideration of whether, and how, the question has been answered already. For instance, alcohol and tobacco are currently legal for recreational use: Why? What criteria pertain in these cases?

As for medical use: Benzodiazepines, such as Valium, are legal. Not only are these drugs potentially addictive, but they are among the few addictive substances (along with alcohol) from which withdrawal can be lethal. Benzos are incomparably more dangerous than marijuana. Why are these drugs legal and in current use? What are the relevant criteria?

Similarly, Dilaudid, which is a synthetic version of morphine, related to it and heroin, and many times more potent than either, is legal and in current use. Cocaine is legal and in current use in every hospital emergency room. Why? What are the relevant criteria? Asking whether or not marijuana might have legitimate medical application is a lot less provocative once we've conceded that cocaine already does. (It is used, by the way, in a dilute solution to treat severe nosebleeds.)

Should assisted suicide be legal? This is another poor question, inviting nothing but emotional responses and perhaps some religious moralizing. A better question is: Are there any circumstances in which allowing death to occur represents the best means of alleviating pain and preserving dignity? We should wrestle with that one--thinking of ourselves or the person we love best in the world in the hot seat--first. Then, we might constructively move on to: What, exactly, do we mean by "allowing"?

Even such words as "marijuana" and "suicide" are tepid in comparison to "abortion," a topic I broach only rarely, with caution and some degree of trepidation. But even where passions are most inflamed, we might turn down the heat by asking better questions. What evidence-based approaches most reliably reduce the frequency of abortions, legal or otherwise, in any given society? Since reducing the demand for abortions is good for all concerned, we might constructively start a discussion there, and might manage to avoid calling one another names or throwing things.

A recent, and already notorious, meta-analysis by Katherine Flegal and colleagues at the CDC suggests that death rates do not necessarily rise or fall with body weight. Asking, in reaction to this--is obesity important after all?--is misguided and silly. Good questions are: Who were the thin and heavy people with higher and lower death rates? Is extra body weight sometimes helpful, and if so, when? Is extra body weight sometimes harmful, and if so, when? We in fact have answers to all of these questions, but they are lost in a haze of hyperbolic nonsense if we fail to ask them.

And then, there is the vexing issue of the lingering, post-Newtown moment: What of that Constitutionally-protected right to bear arms? Asking this question, or any question remotely like it, is a surefire way to get everybody reaching for their respective triggers. It, and all variations on the theme of asking what the Founders really meant, may be diverting for Constitutional scholars, but it's mostly a boondoggle for the rest of us.

The exact words of the Second Amendment are: "A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed."

What are good questions that derive from this? Two occur to me, and they are as obvious as they are simple: Which people? And, what arms?

I trust we can agree, from the most devout pacifist to the NRA leadership, that the Second Amendment cannot possibly mean all people. It can't mean prison inmates, incarcerated for violent crime. It probably can't mean felons on parole after violent crime, either. It can't mean people committed in a psychiatric ward for paranoid schizophrenia. It can't mean 2-year-olds. I don't think any of this is even remotely controversial.

But if "the people" does not, and cannot, mean all people, and if the Founders did not further specify which people, then that is a question we are obligated to ask and answer. Which people? Once we agree it requires an answer, a potentially constructive dialogue ensues.

And, similarly, what arms? Those who feel the Founders anticipated our era of Bushmasters must concede that if so, they envisioned nuclear weapons as well. The Founders either were omniscient and prescient, or they weren't. If they were, and they did envision nuclear weapons, why didn't they say: arms except nuclear weapons? Did they mean individuals should have a right to nuclear arms? Is this a case even the NRA wants to make?

If not, the Founders left it to us to determine what arms made sense. So that becomes a good question: What arms do make sense? We don't have to answer it. We just have to recognize the legitimacy of the question.

Again, I suspect that across the spectrum of opinion here we can agree that individual citizens should not possess a biological weapon, such as smallpox, capable of wiping out the entire population indiscriminately. Individual citizens should not have nuclear missile launch codes. No need to go on, the point is clear. The right to bear arms can't possibly mean all arms. So we are invited to ask: What arms? Again, the question could lead to constructive dialogue unencumbered of hostility.

When I write about the factors contributing to epidemic obesity and ill health, as I often do, I routinely get pushback. Those who think everything is a matter of personal responsibility--that we would all be thin and healthy if we weren't lazy gluttonsconsider me a member of the nanny-state food police. Those who believe in the extreme of environmental determinism aren't shy about calling me a food industry apologist, when I suggest that our food supply may have something to do with demand.

But the barrage of resistance and reproach from those who don't like my answers leads me perennially back to the same conclusion. I think we are wonderfully adept as a culture at asking all the wrong questions.

Epidemiology should trump ideology, mine, as well as yours. For our efforts to do good for real people in the real world, they have to be based on the actual evidence of what our actions do to and for actual people in the real world, not hypothetical abstractions born of hazy hope or morbid fantasy.

Gertrude Stein famously told us: "A difference, to be a difference, must make a difference." Data-driven public policy would address what differences our differences of opinion actually make, and thereby give us a far better platform for action, based on better answers.

But, of course, our only hope of moving in that promising direction begins with asking the right questions.

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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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, 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.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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