11 Replies to “A thought experiment”

1. Michael Ditto says:

   April 4, 2004 at 8:28 pm

   Pink ribbons are for breast cancer.

2. BH says:

   April 4, 2004 at 8:40 pm

   I catch your point here but still don’t really have a problem with this.  Same with new livers for alcoholics.

   The entire reason I don’t like nanny-ism (sp?) is that it implies people don’t own their bodies.  The issue the article raises is just the responsibility inherent with an individual’s choice.

   To my mind, AIDS is so much trickier because lots of people aren’t really making a choice.  I tried but couldn’t find a good article I read about the rapid spread of AIDS in Africa (Economist maybe) having much to do with the appalling mistreatment of women.  Their getting AIDS wasn’t deciding against a condom, it was being sold into urban prostitution and the repeated rapings.

3. Jen says:

   April 4, 2004 at 9:38 pm

   BH, I’m unclear as to why the article wouldn’t bother you, if you don’t support the idea of a nanny state: after all, doctors deciding whether or not you can have elective (which, incidentally, is not covered by many health insurance plans) surgery based on your personal lifestyle choices, is essentially being a nanny.

   Let the smokers have their elective surgery. Just make sure the language in their signed waiver clearly indicates the risk, and guards against unnecessary lawsuits.

   Jeff,AIDS is a red ribbon. Mike is right about a pink ribbon…that’s breast cancer (she said, while wearing her pink ribbon work out shirt, after a training walk for the Breast Cancer 3-Day. Heh.)

4. smith says:

   April 4, 2004 at 10:07 pm

   I want people to know that the gutless and self-pitying Nathan Newman, friend of Ramsey Clark, has been deleting posts that refer to the obits of the 4 men murdered in Iraq (you know: the men that the definitionally challenged Mr Newman calls “mercenaries”). I think that the sensitive Mr Newman gets more exercised about people who take down “Vote Union” fliers in the break room at Wal-Mart than he does about the gruesome murder of 4 innocent individuals.

5. BH says:

   April 4, 2004 at 10:36 pm

   Jen, I normally go your way on these things but after reading the article at the MJA website I found the effect of smoking to be significant enough (they refer to it as being on par with not taking antibiotics before orthopedic surgery) that I can easily understand why doctors would not in good conscience perform some of these surgeries without making sure people hadn’t smoked for 6 weeks.

   Doctors often make these kind of distinctions.  For instance, as a young teenager, a doctor wouldn’t give me an elective tonsilectomy until I could show that I had numerous instances of strep throat in a certain time period.  He wouldn’t just do it because I wanted it (or more appropriately for my age, my parents wanted it).  Doctors, like lawyers, have a tradition of not always doing what we think is right but rather what they think is right.  Indeed, the waiver you suggest wouldn’t be legally enforceable if there was any proof they were being negligent.

6. Jeff G says:

   April 4, 2004 at 10:44 pm

   Sorry, y’all:  threw this post up on the way out the door to buy diapers and a baby swing.  Yes, red is the correct ribbon color (thanks Mike), which I remembered as we pulled into the Babies’R’Us parking lot (thank you, “Seinfeld”). Made the correction.  And my problem with this is simply that I can already foresee a slippery slope (I know, I know, never happen), because there are plenty of instances of medicine becoming politicized.

   Perhaps in retrospect I should have used “McDonald’s frequenters” or “social drinkers” as the fill-in for the thought experiment, but I was looking for a group with known healing problems, and AIDS patients were the first to spring to mind.  Plus I was in a hurry.

7. BH says:

   April 4, 2004 at 10:56 pm

   Jeff, the phenomenom you mention is quite real.  I’ve gotten into some lengthy arguments with Ben Thornton (not his real name, but a real doctor now) over gun control as a public health issue.

8. Jeff G says:

   April 4, 2004 at 11:14 pm

   …So you see where my concern comes from, then?  I’m just very wary of setting these kinds of precedents.

9. BH says:

   April 4, 2004 at 11:56 pm

   I definitely understand the concern.  Some of the issues raised in the article on the MJA site seemed trifling enough to me (no doctor, I, of course) that it did trigger my science-as-politics detector.

   I just didn’t mention it because it somewhat undercut my point.

10. Chaos Overlord says:

    April 5, 2004 at 1:04 am

    IT is absolutely ridiculous to penalize smokers more than they already do.  If you take all of the tax money that smokers pay over the course of their lives, you will find that not only should the government not be sueing tobacco companies but they should be paying for their medical treatment without deductible. 

    AIDS patients pay no such tax, in fact they are obviously not even paying for the research costs explaining the incredible cost of AIDS medication. 

    Or maybe I’m just an idiot.

11. Ben Thornton says:

    April 6, 2004 at 7:51 pm

    The evidence presented in the editorial suggests that complications are more likely in smokers based on several historical observations and that the newest study demonstrates improved outcomes for patients who are prospectively randomized to smoking cessation.  This is a powerful endorsement for smoking cessation, but the editor’s assertion is only a summary of mostly retrospective (read: hypothesis generating not confirming) evidence.

    On the surface, the author goes a bit far to suggest that there should be surgery with-held from individuals who do not quit smoking based on the increased morbidity and a drain on resources.  (Aside: there is a whole lot of debate about the use of pre-operative antibiotics, but that is a whole different matter)

    His retrospective evidence is divided in to two classes of elective procedures: cosmetic/plasic and palliative (joint replacement).  In the first case, the patient pays for all costs out of pocket (in most cases) in both the US and Australia.  In the second scenario, a knee replacement, the cost is picked up by most US insurance and by the national plan in Australia.  He alludes to the fact that in socialized systems the scarce-resources model insures that virtually no one receives these anyway.

    In the US, the prospect of joint replacement is already daunting for the surgeon.  Any predictor of increased morbidity puts the surgeon at a liability risk.  Any predictor of increased morbidity/mortality should be weighed carefully by both the surgeon and the patient in formulating a treatment plan.  Poor wound healing, infection risk, prolonged hospitalization risk (with associated pneumonia and blood clot risk and bed sore risk) and co-morbid disease are already used by surgeons and anesthesiologists to make pre-operative decisions.

    With all that in mind, there is a great deal of medical literature from Canada and the UK about cost-cutting measures.  In the setting of a joint replacement, there is little hope that the surgery would ever take place, it would just help shorten the list.  In the setting of cosmetic surgery (either in the US or Australia), there is little hope that the surgeon will refuse cash.

    As another aside, alcoholics who have undergone treatment for alcoholism, as a group have one of the highest success rates for liver transplants.  This is due in large part to the very high rate of recurrence in the next largest group of transplant candidates, those with end-stage hepatitis.

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