Check out this darkly humorous advertising campaign from the U.S. Department of Health and Human Services. How do you convince men to go to the doctor and get the preventive healthcare that’s known to save lives? You make it all about television. Men + HD TV = “Yes.” This video is funny on so many levels.
*This blog post was originally published at The Happy Hospitalist*
If you’ve spent anytime on The Happy Hospitalist in the last two years, you know I am a strong believer in lifestyle as the only solution to an economic disaster we find ourselves in. One recently reported television health statistic confirms, once again, the strong correlation between lifestyle and early death.
I blogged previously about studies showing an 80% reduction in heart disease, strokes, cancer and diabetes by adhering to lifestyle choices proven to save lives. America is a nation of couch potatoes. Everyday I see families, doctors and nurses taking the elevator up on story to the next floor above. What ever happened to using the stairs for a little self sacrifice?
The television health statistics in this country are alarming. How many hours a week do Americans spend watching television? 1 How does 31 hours a week sound. That’s amazing. I have one or two shows a week that I watch, if I’m lucky. Read more »
*This blog post was originally published at The Happy Hospitalist Blog*
I guess the theme this week is “when things go wrong.” It seems like just when I think we are getting a grip on public health issues like smoking and violence against women, something appears to shake up my naive belief that we are making progress.
Last month the Parents Television Council (PTC) reported that incidents of violence against women on mainstream U.S. TV has increased by 1.2 times in the past five years with the depiction of teen girls as victims being four times as high as it was five years ago. This particular type of violence seems to be increasing at a higher rate than just regular violence, which makes it worse.
Singled out as the worst offender was Fox which the PTC said allows violence against women to be trivialized through punch lines in comedies like “Family Guy” and “American Dad.” Faring the best was ABC (that is, until the AMA Award show last week) which apparently was the only network not showing a dramatic increase in the number of stories that included beating, violent threats, shooting, rape, stabbing and torture. Read more »
This post, Television Violence Against Women On The Upswing, was originally published on Healthine.com by Nancy Brown, Ph.D..
I have not posted a blog in a week because we were on vacation and truly wanted to be on vacation and not be tied to doing any “work.”
We went to north Georgia for a few days then up to the mountains in western North Carolina. How gorgeous! It was so nice to escape the humidity of Florida for a week!
I had an observation on my vacation that I thought I would share. I have talked in previous blogs about mindless eating and how we multi-task while we are eating. When we are not conscious of what we are eating, we don’t fully enjoy it. In addition, we eat more than we realize.
I observed this phenomenon in my little boy who just turned 2 years old. We were in the car a lot for hours on end, so snacking and fast food were part of the trip. Also, because he is 2 and difficult to entertain in a car, we had the DVD player set up for him to watch his favorite Elmo, Clifford, and Thomas the Tank Engine videos.
It was quite amazing that whenever he was glued to the TV, he ate whatever snacks or meals in his carseat without even looking down. He just picked up a piece and put it in his mouth. And he would ask for more. Whenever he was not glued to the TV, he wasn’t asking for food or eating as much. Hmmm…..very interesting.
From now on I am going to be very careful about two things. First, how much TV he is watching. He normally doesn’t watch much but on this trip he got very spoiled with watching his DVD’s and I am afraid it will lead to more asking to watch now that we are home. Second, I am going to only let him snack when he is fully conscious of what he is doing. No food in front of the TV so that he can be very conscious about what and how much he is putting into his mouth.
As a fairly new (2 years) parent, I am still learning these lessons first hand on how to feed children. I just had to share my story because our children learn habits, both good and bad, at a very young age!
This post, Do 2 Year Olds Engage In Mindless Eating?, was originally published on Healthine.com by Brian Westphal.
DrRich thanks the Cockroach Catcher (his favorite retired child psychologist) for pointing him to an article (by Mark Wicclair, a bioethicist) and an accompanying editorial (by Deborah Kirklin, a primary care physician) in the peer-reviewed medical journal, Medical Humanities, which deconstruct the television show “House MD.”
A TV show may at first glance seem a strange subject for a medical journal, but this is, after all, a journal whose subject is the “softer” side of medical science. (DrRich hopes his friend the Cockroach Catcher will take no offense at this characterization, and directs him, in the way of an apology, to the recent swipes DrRich has taken at his own cardiology colleagues for their recent sorry efforts at “hard” medical science.) Besides, the Medical Humanities authors use the premise and the popularity of “House MD” to ask important questions about medical ethics, and the consequent expectations of our society.
DrRich does not watch many television shows, and in particular and out of general principles he avoids medical shows. But he has seen commercials for House, and has heard plenty about it from friends, so he has the gist of it. The editorial by Dr. Kirklin summarizes:
“[House] is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary.”
Given such a premise, the great popularity of “House MD” raises an obvious question. Dr. Kirklin:
“… why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House?”
Indeed. While it has not always been the case, maintaining the autonomy of the individual patient has become the primary principle of medical ethics. And medical paternalism, whereby the physician knows best and should rightly make the important medical decisions for his or her patient, is a thing of the past.
It has been formally agreed, all over the world, that patients have a nearly absolute right to determine their own medical destiny. In particular, unless the patient is incapacitated, the doctor must (after taking every step necessary to inform the patient of all the available options, and the potential risks and benefits of each one) defer to the final decision of the patient – even if the doctor strongly disagrees with that decision. Hence, the kind of behavior which is the modus operandi of Dr. House should be universally castigated.
So, the question is: Given that House extravagantly violates his patients’ autonomy whenever he finds an opportunity to do so, joyfully proclaiming his great contempt for their individual rights, then why is his story so popular? And what does that popularity say about us?
To DrRich, the answer seems quite apparent.
The notion that the patient’s autonomy is and ought to be the predominant principle of medical ethics, of course, is entirely consistent with the Enlightenment ideal of individual rights. This ideal first developed in Europe nearly 500 years ago, but had trouble taking root there, and really only flowered when Europeans first came to America and had the opportunity to put it to work in an isolated location, where rigid social structures were not already in place. The development of this ideal culminated with America’s Declaration of Independence, in which our founders declared individual autonomy (life, liberty and the pursuit of happiness) to be an “inalienable” right granted by the Creator, and thus predating and taking precedence over any government created by mankind. And since that time the primacy of the individual in American culture has, more or less, remained our chief operating principle. Individual autonomy – or to put it in more familiar terms, individual freedom – is the foundational principle of our culture, and it is one that is perpetually worth fighting and dying to defend.
So the idea that the autonomy of the individual ought rightly to predominate when it comes to making medical decisions is simply a natural extension of the prime American ideal. Of course, most think, this ought to be the governing principle of medical ethics.
But unfortunately, it’s not that easy. There’s another principle of medical ethics that has an even longer history than that of autonomy – the principle of beneficence. Beneficence dictates that the physician must always act to maximize the benefit – and minimize the harm – to the patient. Beneficence recognizes that the physician is the holder of great and special knowledge that is not easily duplicated, and therefore has a special obligation to use that knowledge – always and without exception – to do what he knows is best for the patient. Dr. House is a proponent of the principle of beneficence (though he is caustic and abrasive about expressing it). DrRich believes House is popular at least partly because the benefits that can accrue to a patient through the principle of beneficence – that is, through medical paternalism – are plain for all to see.
Obviously the principles of beneficence and of individual autonomy will sometimes be in conflict. When two worthwhile and legitimate ethical principles are found to be in conflict, that is called an ethical dilemma. Ethical dilemmas are often resolved either by consensus or by force. In our case, this dilemma has been resolved (for now) by consensus. The world community has deemed individual autonomy to predominate over beneficence in making medical decisions.
DrRich’s point here is that Dr. House (the champion of beneficence) is not absolutely wrong. Indeed, he espouses a time-honored precept of medical ethics, which until quite recently was THE precept of medical ethics. There is much to be said for beneficence. Making the “right” medical decision often requires having deep and sophisticated knowledge about the options, knowledge which is often beyond the reach of many patients. And even sophisticated patients who are well and truly medically literate will often become lost when they are ill, distraught and afraid, and their capacity to make difficult decisions is diminished. Perhaps, some (like House) would say that their autonomy ought not be their chief concern at such times. Indeed, one could argue that in a perfect world, where the doctor indeed has nearly perfect knowledge and a nearly perfect appreciation of what is best for the patient, beneficence should take precedence over autonomy.
It is instructive to consider how and why autonomy came to be declared, by universal consensus, the predominant principle of medical ethics. It happened after World War II, as a direct result of the Nuremberg Tribunal. During that Tribunal the trials against Nazi doctors revealed heinous behavior – generally involving medical “research” on Jewish prisoners – that exceeded all bounds of civilized activity. It became evident that under some circumstances (circumstances which under the Nazis were extreme but which were by no means unique in human history) individual patients could not rely on the beneficence of society, or the beneficence of the government, or the beneficence of their own doctors to protect them from abuse at the hands of authority. Thusly was the ethical precept which asks patients ultimately to rely on the beneficence of others starkly revealed to be wholly inadequate. The precept of individual autonomy, therefore, won by default.
Subsequently, the Nuremberg Code formally declared individual autonomy to be the predominant precept in medical ethics, and beneficence, while also important, to be of secondary concern. Where a conflict occurs, the patient’s autonomy is to win out. It is important to note that this declaration was not a positive statement about how honoring the autonomy of the individual represents the peak of human ethical behavior, but rather, it was a negative statement. Under duress, the Nuremberg Code admitted, societies (and their agents) often behave very badly, and ultimately only the individual himself can be relied upon to at least attempt to protect his or her own best interests.
DrRich will take this one step further. When our founders made individual autonomy the organizing principle of a new nation, they were also making a negative statement. From their observation of human history (and anyone who doubts that our founders were intimately familiar with the great breadth of human history should re-read the Federalist Papers), they found that individuals could not rely on any earthly authority to protect them, their life and limb, or their individual prerogatives. Mankind had tried every variety of authority – kings, clergy, heroes and philosophers – and individuals were eventually trampled under by them all. For this reason our founders declared individual liberty to be the bedrock of our new culture – because everything else had been tried, and had failed. In the spirit of the enlightenment they agreed to try something new.
There is an inherent problem with relying on individual autonomy as the chief ethical principle of medicine, namely, autonomous patients not infrequently make very bad decisions for themselves, and then have to pay the consequences. The same occurs when we rely on individual autonomy as the chief operating principle of our civil life. The capacity of individuals to fend for themselves – to succeed in a competitive culture – is not equal, and so the outcomes are decidedly unequal. Autonomous individuals often fail – either because of inherent personal limitations, bad decisions, or bad luck.
So whether we’re talking about medicine or society at large, despite our foundational principles we will always have the tendency to return to a posture of dependence – of relying on the beneficence of some authority, in the hope of achieving more overall security or fairness – at the sacrifice of our individual autonomy. In DrRich’s estimation the popularity of “House MD” is entirely consistent with this tendency. (Indeed, the writers almost have to make Dr. House as unattractive a person as he is, just to temper our enthusiasm for an authority figure who always knows what is best for us and acts on that knowledge, come hell or high water.)
Those of us who defend the principle of individual autonomy – and the economic system of capitalism that flows from it – all too often forget where it came from, and DrRich believes this is why it can be so difficult to defend it. We – and our founders – did not adopt it as the peak of all human thought, but for the very practical reason that ceding ultimate authority to any other entity, sooner or later, guarantees tyranny. This was true in 1776, and after observing the numerous experiments in socialism we have seen around the world over the past century, is even more true today.
Individual autonomy will always be a very imperfect organizing principle, both for healthcare and for society at large. Making it an acceptable principle takes perpetual hard work, to find ways of smoothing out the stark inequities, without ceding too much corrupting power to some central authority. This is the great American experiment.
Those of us who have the privilege of being Americans today, of all days, find ourselves greatly challenged. But earlier generations of Americans faced challenges that were every bit as difficult. If we continually remind ourselves what’s at stake, and that while our system is not perfect or even perfectable, it remains far better than any other system that has ever been tried, and that we can continue to improve on it without ceding our destiny – medical or civil – to a corruptible central authority, then perhaps we can keep that great American experiment going, and eventually hand it off intact to yet another generation, to face yet another generation’s challenges.
*This blog post was originally published at the Covert Rationing Blog.*
It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…
I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…
Book Review: Is Empathy Learned By Faking It Till It’s Real?
I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…
The Spirit Of The Place: Samuel Shem’s New Book May Depress You
When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…
Eat To Save Your Life: Another Half-True Diet Book
I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…
