A Philosopher's Blog

Philosophical Essays on Many Subjects

Medicine/Health

What I’ve Learned About Health Care

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As I recovery from the surgery that repaired my torn quadriceps tendon,  I have had the chance to reflect on health care. Although I have been to the doctor in the past, it was generally for minor stuff-sinus infections, checkups and so on. However, my recent experience was far more serious and hence led me to think more about the matter.

First off, health care is expensive. With my insurance, the surgeon charged me about $400 for the operation. My insurance covered 80% of the cost, so the operation itself cost $2,000. The procedure took less than an hour. I have yet to receive the hospital’s bill, which I suspect will be even more than the surgeon’s fee.

Since I have good insurance and a good job, I can afford to pay. However, if I did not have insurance or a good income, that $2,000 alone would be a fairly serious hit. While I have long been for reducing medical costs, I am even more for it now that I have a concrete experience to ground my previously abstract arguments.

Naturally, I have no objection to paying a skilled professional a significant amount of money. As a professor, I get paid fairly well and that is justified because of my education, skill, and experience. Likewise for medical doctors. However, the costs need to be reduced so that people can afford health care. Just how to do this is, of course, the big question.

Second, as a patient you need to be very active in your own health care. The first doctor I went to checked to see if my leg was broken, gave me  a prescription and sent me on my way without a referral or any advice beyond icing the knee. The second doctor I saw said that they could not do an MRI because it was not considered an emergency, but I did get a referral after he took a quick look at my leg. I finally got to see a specialist one week after my initial accident. The doctor was very good and diagnosed the injury within a minute. I was scheduled for surgery the next day.

As my example indicates, it is important to always get a second opinion (and a third) when you suspect it might be something serious. If I had simply stuck with the first doctor, it might have been much longer before I got a proper diagnosis.

Third, as a patient you have to educate yourself. I have found that doctors tend to provide very minimal information at best. While some might say that doctors do this to preserve the illusion that they are keepers of a special knowledge beyond the keen of normal mortals, I think that they do this for a much more innocent reason. To be specific, doctors are trained to diagnose and treat illness and injuries rather than to teach.

In contrast, I am trained to teach. So, I provide detailed, clear and (hopefully) interesting explanations, instructions and explications. Naturally, I notice when someone else fails to do this and I notice that doctors and nurses generally fail to do this. To be fair, this is mostly not their fault. They are not trained to be teachers or to clearly convey information to the patients.  To show the contrast, my students get a 16 page guide to write a 6-10 page paper in my Modern class while I got two generic bullet lists and a few minutes of instruction about how to deal with three medications (including a blood thinner that would need to be injected) and my knee.

Given that the medical profession is already overloaded, it is unlikely that patient education is going to be a priority in the near future. It is also unlikely that hospitals and clinics will start to widely employ medical educators to teach patients about their medications, treatment, condition and so on.

As such, it is up to the patient to provide self education. Fortunately, there are many sources of information such as the old standby of books (the various Mayo Clinic publications are a good place to start-they tend to be informative, accurate and readable) and, of course, the web. You need to be very careful about the web. While places like WebMD are professional sites, there are plenty of dubious and scam sites out there. Some are just honestly misguided (for example, people who sincerely push copper bracelets as a cure for arthritis) while others are snake-oil-salesmen who sell useless or harmful products. My best advice is to stick with the professional  sites and cross check any information you find elsewhere.

If you are up to the challenge, some medical journals are available online (google will find them) and they can be useful. On the downside, they are written by professionals for professionals, so they are often a bit too technical for most folks.

People also tend to rely on anecdotal claims from friends and colleagues. While such advice can be well intentioned and even useful, it is always good to verify any advice that might seem a bit dubious. After all, anecdotal  evidence isn’t a fallacy for nothing.

Fourth, I learned that good friends make even a disabling injury bearable. Thanks Florence, Ron, Dave, Kyle, Bridgette, Anna, and everyone else!

One Week After Surgery

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A week ago I underwent surgery to repair the torn quadriceps tendon in my left leg. That was, as you might imagine, not one of the more enjoyable experiences of my life.

At this point, I’m doing better than I expected. While I do have some trouble sleeping (you would not believe the nightmares I had for a while-most involving my knee cap popping out of my leg) and my leg is immobilized, my outlook is still positive and I have not (as of yet) had any psychotic episodes. Since I’m a running fanatic and haven’t been able to run in a couple weeks, I am worried that it is just a matter of time.

Today was the day I was finally allowed to change the dressing on the wound. Fortunately, one of my close friends, Ron,  is married to a nurse and she agreed to help out. As she peeled away the various layers of bandages, I vaguely wondered what horrors I would see. Fortunately, the bleeding had been very minimal and the incisions were already healing nicely. Of course, it was just a bit creepy to see shiny metal staples sticking in my flesh. Naturally Ron took a picture of the knee-he is a sensitive sort of guy.

Seeing that things were healing up nicely helped keep my morale up and being able to reduce the amount of gauze stuffed under the immobilizer has been great. This coming Thursday I am supposed to get the staples removed (I wonder if I can keep them…) and a hinged knee brace. Since I plan on using a stationary bike (thanks Dave!) to keep my cardio health up, it will be nice to have something that will handle sweat better. The immobilizer handles sweat by absorbing it and then getting stinky. Hardly an optimal solution.

I am supposed to be able to go back to work the week after next-I’m looking forward to that. Grinding through student emails, downloading student papers, and setting up two weeks worth of classes online has made me work way too much for someone out with an injury. On the plus, side, it has kept me busy and given me a continued sense of purpose.

Surgery

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As I mentioned in earlier blogs, I tore/ruptured my quadriceps tendon. On Friday I went in for surgery. This was my first time under the knife, so I was a bit worried. Fortunately, it all went well.

Florence drove me to Tallahassee Memorial Hospital and we arrived at the parking garage. TMH is a large hospital (relatively speaking) and grew in a rather haphazard way. As my friend Ron put it, it looks like they just put up the new buildings “wherever” and used “whatever” style that came to mind at the time. Fortunately, I ran into a nice fellow who was working there and he knew where to go-he even gave me a lift in his “golf cart.”

Once I got into the hospital I was checked in by a former student. It was kind of funny-like one of those commercials for the Visa check. She said “Dr. LaBossiere, what did you do to yourself?” Then, a few minutes later “I need to see your photo ID.” Of course, I know that they have to do that. But is it still kind of funny.

After that I went to my room, which was also the room for another Michael. He was in for a hernia repair. Naturally, I had to strip down and put on one of those gowns. Apparently, showing one’s ass to the world is a critical part of the medical process. After that, I had blood taken and an IV put in.

I was then wheeled down to the pre-op and met the nurses, anesthetist, and doctor. I learned that I’d probably not be able to run for 9-12 months. A short while later, the anesthetist did his stuff and I fell asleep. I woke up in the recovery room attached to the monitoring equipment and then I was brought back to my room.

I spent a couple hours recovering after that and talked with the PA for a couple minutes about what to do and not do; then Florence drove me home and has been taking care of me ever since. Naturally, I call her “Florence Nightingale.”

Reasoning, Autism & Vaccines

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Good parents are protective of their children and fear things they think could do them harm. Unfortunately, parents (like anyone else) can be mistaken about what is and is not harmful. This can occur because, ironically, people tend to reason poorly when they are afraid. This is ironic because such situations are when we really need our reasoning skills the most. One such situation is the controversy over vaccines and autism.

Dr. Paul Offit recently wrote a book on the subject, Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure, that has generated a great deal of controversy. One of the purposes of the book is to address the alleged causal link between vaccines and autism. His position, which is well supported by the weight of scientific research, is that vaccines do not cause autism and are safe for children.

Despite the fact that the weight of evidence shows that vaccines (including the thimersol that was once used as a preservative in some vaccines) do not cause autism, many people still believe there is a connection. Part of this is due to the fact that a now retracted 1998 study suggested a link between vaccines and autism. Part of this is due to the fact that lawyers, celebrities, and people in the media continue to claim that there is a connection. Even John McCain asserted his belief in the connection. In some cases, these people are honestly mistaken. In other cases, they stand to benefit from such claims.

Not surprisingly, Offit is the target of anger and even threats. In the case of people who are willfully misleading the public, this is to be expected. In the case of people who are honestly mistaken, this might seem surprising. After all, one would think they would be grateful to know the truth. Of course, there are those who doubt that Offit has the truth.

Offit’s critics contend that he stands to gain financially from vaccines and hence is biased. Offit profited from the sale of the vaccine RotaTeq and has also been a paid and unpaid consultant for the drug company Merck (which now manufactures RotaTeq).

From a critical thinking standpoint, this concern is reasonable. After all, a person’s credibility is reduced to the degree that they are biased and money is a strong biasing factor. When people raise this concern, they are reasoning well-provided that they are raising it on good grounds and not as a rationalization for their rejection of his claims.

While money is a biasing factor, when assessing the credibility of a source it is also important to consider the whole picture and not just one factor. To do otherwise would be fall victim to a bias. Offit’s personal history and behavior seem to indicate that he is more concerned about the well being of children than about money and people do speak highly of him. These factors might very well offset any bias from his financial ties to vaccines and, of course, his scientific credentials are quite solid.

Fortunately, resolving the key issue (whether vaccines cause autism or not) does not depend on Offit’s credibility alone. There has been extensive research into the alleged connection between vaccines and autism and, as noted above, the weight of the evidence is overwhelmingly against there being a meaningful connection. Why, then, do people still believe that there is a connection?

First, as mentioned above, there are celebrities, people in the media, lawyers and others who claim that there is a connection. People are often bad at discerning between legitimate authorities on a subject and people speaking on that subject who are famous for something else (like being an actor). When people make this error they are committing a fallacious appeal to authority.

Second, people are generally poor at scientific reasoning and critical thinking. Even college educated people. My own university’s assessment process revealed that most of our students are weak in these areas and similar assessment at other schools have revealed similar results. These results match my own experiences teaching critical thinking. When people are not very good at scientific reasoning and critical thinking, they tend to not know how to assess such research and also tend to be less influenced by logical arguments. Instead, they tend to be more influenced by emotional factors and poor reasoning. This leads to the third reason.

Third, people are more influenced by their emotions than by reason. Many parents are worried that their child will develop autism. Thus, fear and love leads them to be concerned about anything that might cause autism. These emotions can impede their ability to assess the matter rationally and they can come to feel that vaccines are a threat when they hear about the connection. If they are not good at critical thinking, they will not be able to properly investigate the matter and hence will tend to stick with how they feel rather than finding out what would be most rational to think.

Fourth, most people tend to be more influenced by poor reasoning than by good reasoning. As I tell my students, fallacies tend to be far more persuasive than logical arguments. After all, people tend to feel far more strongly than they think. Further, people tend to fall into very predictable patterns of poor reasoning and accept the results as true.

In the case of autism and vaccines, people seem to fall into the post hoc fallacy. This allacy derives its name from the Latin phrase “Post hoc, ergo propter hoc.” This has been traditionally interpreted as “After this, therefore because of this.” This fallacy is committed when it is concluded that one event causes another simply because the proposed cause occurred before the proposed effect. In the case at hand, parents might notice their child showing signs of autism after receiving vaccinations and assume that the vaccinations are the cause. However, without adequare evidence linking the two, this would not be a reasonable inference.

Fifth, when people do not know what is causing something harmful, they can start grasping at explanations. People, sensibly enough, do not like being ignorant of what is causing autism. While this does motivate people to search for a cause, it can also lead people to simply pick an explanation so that they now feel more in control. Of course, if someone does not have a good grasp of critical reasoning, they can accept something as a cause that really is not. For example, people have explained illnesses and deaths in terms of witchcraft, curses and vampires. Today, few people would attribute autism to supernatural causes, but taking vaccines as the cause without adequate evidence can be seen as somewhat similar: a cause (or scapegoat) must be found to make people feel better.

Does this mean that vaccines have no possible link to autism and the people who worry about it are foolish? No, clearly not. There could be cases in which a vaccine has triggered autism by interacting with many other factors and it is reasonable to be concerned about such a possibility. However, it is also important to approach the matter rationally and not let fear lead people into making unwise choices.

After all, while there is the possibility that vaccines might have some link to autism, it is well established that vaccines protect children from very real harms. Some parents, afraid of the alleged link, have not vaccinated their children or are not following the recommended schedules. Given the serious consequences of some of these diseases, a failure to vaccinate properly could be very harmful to the children. Naturally, these vaccines should be made as safe as possible.

Tanning Beds

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Tanning Bed

While the sun provides free tanning, it is not always reliable. This is why people often turn to tanning beds.  When I first heard of tanning beds (or “fake bakes” as they were called), they struck me as a bad idea. My view was supported by various tanning bed horror stories told to me by one of my grad school roommates. She was a nurse, so she had first hand experience with the various negative consequences of tanning beds.

While the dangers of skin cancer have been well publicized, people continue to use tanning beds. Part of this is due to the fact that the tanned look has remained popular and is considered a sexy look.  This has not always been the case. Many years ago, the pale look was considered the proper look for white women. Another part of the reason is that the Indoor Tanning Association has been conducting a pro-tanning ad campaign. The campaign addresses the health concerns about tanning by making use of findings about vitamin D. As has long been known, the body will naturally produce vitamin D when exposed to sunlight. Vitamin D is rather important and has various health benefits.

However, what the ITA campaign fails to mention is that a person can get enough sunlight to generate an adequate amount of vitamin D fairly quickly.  For pale people, the needed exposure time is about 10 minutes. People with darker skin will need about twenty minutes. Further, people can get vitamin D via dietary supplements or as part of food. For people living in areas with inadequate natural sunlight, tanning beds can provide a means of getting UV light. However, for most people the tanning bed is not a good choice. It can also present a health danger. The main danger is, of course, skin cancer.

Skin cancer cases have been increasing since the 1970s. Part of this is due to changing behavior and dress, part is also due to environmental changes and part seems to be due to tanning beds.

The prime demographic for tanning beds are 15-29 year old females and this group has a larger incidence of skin cancer than males of the same age. Dr. Anir Dhir, a dermatologist in Lexington, Kentucky notes that of the  800 cases of melanoma he has treated, “60 of them were in women younger than 30 years old, and all of them were avid tanning-bed users.” Newsweek, March 19 These findings are typical, thus indicating a connection between tanning beds and cancer. This is hardly surprising. It has been established that UV exposure is a causal factor in skin cancer and tanning beds expose people to UV radiation.

It might be wondered why tanning beds are still legal, given that they seem to be clearly a threat to health. The answer is the same as for tobacco-money and organization. The indoor tanning industry brings in about $5 billion a year and has the well organized ITA to fend off attacks.

As with tobacco, most users of tanning beds know that what they are doing is risky. The attitude of many people is best expressed by  Alex Lloyd. She goes to the tanning salon five days each week. She is aware of the risk, but ignores it. In her words: “A lot of people tell me I do it too much, blah, blah, blah. But I just don’t care.” Newsweek, March 19.

From a moral and health standpoint, it seems that she is making the wrong choice in not caring. After all, she is intentionally putting her health at risk in return for merely having a tan. That seems to be rather irrational. It also seems immoral for the tanning salon to provide her with the means to hurt herself.

Of course, it can be argued that people should have the right to harm themselves if they are aware of the risks and accept them. After all, people are allowed to smoke, drink, drive cars, and so on and these activities all put people at risk. While it seems foolish to risk somethings so serious (skin cancer) for something so frivolous (a tan), the freedom to do stupid things seems to be an unavoidable part of freedom. As such, people should be allowed to go to tanning beds.

This, as noted above, assumes that the people are making an informed stupid choice. The ITA seems to be somewhat deceptive in its ad campaign. While it is true that UV radiation does enable the body to create vitamin D, exposure to UV radiation also has serious health risks. To downplay these risks is morally unacceptable and the ITA should be honest about the risks. Natural enough, they can appeal to the fact that almost all advertising campaigns are (by their very nature) acts of deceit, downplaying and so forth. However, the mere fact that everyone does such things hardly makes it right-this is an appeal to common practice.

In sum, it is acceptable for people to use tanning beds, provided that they are informed of the risks they are taking. ITA’s ad campaign does seem to be immoral in that it is trying to get people to engage in a harmful activity by means of what could be regarded as deception.

Doctor Suicides

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One unfortunate statistic is the suicide rate for medical doctors: 300-400 per year. Interesting, the ratio between male and female doctors is 1:1 in regards to suicide. In contrast, the ratio in the general population is 4(male):1(female).

To break it down even more, the suicide ration of male doctors to other males is estimated to be 1.4:1. For women, the results vary from study to study, but a commonly cited figure for female doctors to other females is 2.3:1.

One common hypothesis is that the higher suicide rate is due to untreated depression (see ‘Doctors Who Kill Themselves”, by David Noonan, Newsweek April 28 page 16). While male doctors seem to be depressed at the same rate as non-doctors, they tend (as noted above) to commit suicide more often. female doctors have, based on some studies, twice the rate of depression of female non-doctors.

While one would think that doctors would be more likely to seek treatment because of their education, the opposite is true-they tend to avoid treatment. The main reason seems to be that they fear the impact of such a diagnosis: loss of respect, income and perhaps even their medical license. As such, a doctor is more likely to simply try to deal with depression on their own and hence are more likely to commit suicide than those who seek treatment. Doctors also are more likely to succeed in their attempts-their medical knowledge serves them well in this regard.

Another possible factor is one that is not commonly discussed in this context: the fact that doctors tend to have lower empathy. This has recently been supported by studies but has long been known to philosophers and the English. To be specific, in writing on the rights of animals, Immanuel Kant noted that doctors were not allowed to sit on English juries because their hearts had become hardened. This reduced degree of empathy can be harmful for the patients and a greater degree can be beneficial. This, of course, seems obvious: someone who has more empathy will work better with others, be more inclined to truly help others, and also be more effective in getting the patient to cooperate.

In addition to the effects on patients, it also seems likely that having little empathy would also have an effect on the doctors. A person who is lacking in regards to empathy is less likely to be able to establish healthy relationships that can provide the support needed to mitigate or deal with depression. Such a person is probably more likely to feel isolated and hence also more likely to give in to depression. Further, it seems possible that a person who who has less empathy will have less of a “feeling” as to how their suicide can impact others and hence might be more inclined to end his/her own life.

Fortunately, awareness of the problem of doctor empathy in the medical and academic community is growing. If the proper steps are taken, this might also help reduce the number of doctor suicides.

In addition to the general matter of suicide, the above findings are also interesting in terms of gender. To be specific, while male and female doctors kill themselves at the same rate, the same is not true in the general population. This seems to suggest suicide rates are influenced more by factors other than gender, such as profession. The gender difference in the general population could thus be explained by the differences between the jobs that are traditionally male dominated and those that are traditionally female dominated. Another factor worth considering is the empathy factor-perhaps the medical profession does a more thorough job of crushing empathy than other professions. Women, it is often claimed, are more empathetic than men and hence would be affected more by the damping of their empathy. This would help explain why female doctors kill themselves at rate of 2.3 to 1 relative to the general female population. In contrast, the impact is less on males (the ratio is 1.4:1)-perhaps because men are less empathetic or generally have their empathy dampened throughout life.

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