Deception-Based Medicine

So the Medical Establishment treats us all as unthinking boobs, complete morons, children who need to be protected. Why not? The Government has been doing that for decades.

This reminds me of the medical community’s willingness to essentially fabricate an entire body of science: secondhand smoke. This “science” provided the underpinning for a wayward invasion of property rights and personal liberties. Of course, the ends (reduction of smoking) were justified by the means in the view of the medical obfuscators.

I think the medical community’s binary approach to matters of personal pleasure breeds distrust among those of us who realize that matters of personal consumption involve tradeoffs. I applaud Ms. Oster for analyzing those tradeoffs on her own in the absence of reasonable guidance from the condescending prohibitionists.

I don’t know if Bryan has discussed the issue, but I have in an old blog post.

Question for you James: Would you let the mother of your child consume alcohol while she’s pregnant?

This part of your post seems to sum up the fundamental issue you want to raise in the post:

“the NIAAA clearly has two messages tailored to two different audiences…the language of the specialist…easy-to-understand language. Ordinary people do not receive medical information in an unbiased manner. Instead, medical research is frequently passed through a filter so that it provides only what is prudent to believe. Seemingly, the unspoken belief is that people can’t handle the truth.”

Of course there are the ‘simple’ and the ‘expert’ versions when discussing any bit of medical advice/decision making. There must be some sort of ‘translation’ from the findings of various studies (which may utilize complex statistical analysis, contain various caveats as only certain populations were studied, under specific circumstances) as understood by the medical community to advice that can be given to the patient. As you (would hopefully) understand, the ability to process and act upon that information varies greatly from patient to patient. Therefore, and individual physician may readily give greater ‘expert’ level detail to a patient capable of using such to inform their decision making. However, other patients need a much simpler version. In many practice settings, a large majority of the patient population may sign their name with an ‘X’, read at less than an 8th grade level, or have other impediments to understanding the complexity of something along the lines of “we don’t know the bound below which the risk of such an adverse event becomes zero, please look at these stochastic risk models in chart 1”.

So, if you’re a national organization, it makes sense to offer up broad advice catering to the lowest common denominator, with footnoted explanations of the complex (and often incomplete) underlying science.

And Charley Hooper’s reply is great.

I’m thinking more about the “scientists might not be looking very hard” angle. I imagine solving this question requires just as much work as any other in medicine. But the typical problem leads to huge results, lives saved, and sometimes even lots of cash. New treatment for cancer? Awesome! You’ve saved lives, and people will pay a lot for that. New treatment for vision problems? Great, now people won’t go blind, and they’ll pay for that too, happily.

Definitive answer to fetal alcohol processing? Um…some women will have a slightly more pleasant pregnancy. In a way that it’s impossible to profit from, as a researcher. Plus, if pleasant pregnancy is your goal, I wouldn’t even start here: focus on morning sickness or labor pains or probably a dozen other things that are more of an issue than changing an alcohol ban to an alcohol limit.

I mean, it’s still knowledge, with the potential to lead elsewhere. And proving it would be useful in itself, if small. It wouldn’t be a waste to research. But leaving it as a low priority seems perfectly rational to me.

It’s funny to contrast this with informed consent or use of tainted data as discussed in Caplan’s Mengele post. It seems like the question of when it is okay to make decisions for other people is one for which we don’t have clear answers.

For example, only the fringe rejects the idea that the atomic bombing of Japan, killing about a hundred thousand to save millions, was moral. In this post we see doctors perfectly comfortable lying to patients and helping propagate a lie. In medical research, informed consent rules prevent things from being funded, even when it’s doubtful informed consent is really possible for more than a sliver of the population and the potential benefit may be high.

It’s hard to see an organizing principle, other than maybe that you need to look at the quality of the decision and the effort that went into making it, the implications for the persons you’re making it for, and the costs and benefits, when judging morality. There’s a sliding scale and it probably changes with time.

My biological intuition suggests that an ounce of alcohol would be harmful when applied to a developing brain that weighs not much more than an ounce.

Is there reason to doubt that such exposure is harmful, or does the mother’s metabolism protect the fetus from exposure?

Physicians knew for decades that moderate consumption of alcohol was a net plus for most adults. The major medical societies continued to recommend abstinence. They were afraid of lawsuits from people who didn’t understand ‘moderate’.

The same is true for alcohol use during pregnancy.

The same is true for dietary cholesterol and fats.

They’ve known that caffeine use is harmless or beneficial for decades.

Most physicians believe they are the nannies in a nanny state.

Note: I’ve been a pathologist for 26 years.

@James

“I think there is a cost to piling too many rules on mothers. Not only are mothers people too, but onerous rules might cause some mothers not to give birth in the first place.”

Hahaha! You really think this is an issue of ‘onerous rules might cause some mothers not to give birth in the first place?’ That’s rich. Sure, you can make the intellectual debate that at the margin some mother won’t want to get pregnant because she won’t be able to get wasted every night, but such an argument carries little weight in the real world.

First off, these aren’t rules, they’re recommendations. There is no authority to hold anyone responsible for not following them.

Secondly, all you need to look at is the number of mothers who give birth to multiple children over successive pregnancies who are affected by FAS, suffer the manifold consequences of maternal smoking during pregnancy, or have to go through withdrawal from crack/meth/cocaine or other drugs in their system to see that, if seeing the awful consequences of one child doesn’t discourage a mother from making more choices during pregnancy, a recommendation from an ‘authority’ who has no real authority over her life certainly won’t carry any weight.

The simplified advice isn’t for the woman with a post-graduate education who can understand the data (or lack thereof) and make a decision based on her own understand of the risk-benefit analysis…it’s for the millions of women a year in this country who are marginally literate, don’t have the desire or background to weight the varied evidence for or against the question at hand, and just need a quick, easy to understand soundbyte that relates what is the safest possible generalizeable advice for their situation.

Caplan touted that you, “know the on-the-ground details of how the U.S. health industry actually works.” So, ‘Medical Deception’ makes for an eye-grabbing title, but seems to be a bit deceptive itself. Your fundamental issue seems to be ‘broad national recommendation medical advice is too broad and simplistic’. My question for you would be:

How would you best relate the risks of alcohol consumption to one of the 100’s of thousands of unwed teen mothers who will get pregnant this year?

Oh, and FYI, fetal alcohol syndrome is the most common known non-genetic (non-inherited) cause of mental retardation in the United States. About 40,000 babies are born with FAS each year. This sort of flies in the face of @Daniel Artz snarky comment that ‘the Medical Establishment treats us all as unthinking boobs, complete morons, children who need to be protected. Why not?’

The English have a penchant for understatement, and they develop particular habits of speech around it. This can get them into trouble with foreigners, who are unaware of the implicit rules of English communication. They may not understand that when an English person describes something as ‘a bit of a nuisance’, they may actually mean that it’s pretty much intolerable. However, English people know this about each other, and so they pick up on the understatement and aren’t misled.

Now, it seems to me that, especially in the United States, it’s a cultural presupposition, an implicit norm of communication, that any kind of authoritative organisation will exaggerate dangers and risks. Therefore, people have learned to interpret them with a grain of salt, to assume that the authority is leaving themselves a large buffer between what they recommend and what is actually hazardous by common standards.

Perhaps this situation evolved because of concerns about legal liability. Whatever the case, once a norm like this gets established, then doctors have to deliver their advice in such a way that it will be correctly interpreted, and that means they only appear to exaggerate the dangers. Given the norms governing the communication, they would be misunderstood if they didn’t exaggerate, just like one English person might mislead another by not using understatement when it would be socially appropriate.