Butler Beaudoin

Dr. Emerson

IDMD 102

13 February 2024

Where to Point the Finger?

Qaug dab peg: The Spirit Catches You and You Fall Down. That was the diagnosis Lia’s Hmong community had given her when she started having violent seizures. The American doctors knew the ailment by another name: epilepsy. In Anne Fadiman’s compelling novel, The Spirit Catches You and You Fall Down, the struggle of providing medical treatment across cultural boundaries is vividly depicted. The first four chapters recount the beginning of Lia Lee’s journey and illustrate how cultural assumptions can lead to unfavorable healthcare outcomes. In my presentation, I recounted the events of each chapter and analyzed the significance of their titles.

Chapter one is thoughtfully titled “Birth.” Not only does Fadiman describe the birth of Lia, the beginning of the story, but she also discusses the traditional practices of the Hmong people concerning the birth of a child and how they differ from those of Americans. Chapter two, “Fish Soup,” recounts the history and reflects on the culture of the Hmong people, providing some context for the narrative. Chapter three fittingly shares its name with the novel, “The Spirit Catches You and You Fall Down,” and recounts the onset of Lia’s epilepsy, or qaug dab peg. The language barrier initially prevented Lia’s parents from explaining what happened, and the doctors subsequently misdiagnosed her. “Do Doctors Eat Brains” is a strange title for chapter 4 and a seemingly stranger question to ask regarding western medicine. Still, it seems this is the general perception many Hmong possess regarding physicians in the United States.

These are my discussion questions:

1. In chapter one, most doctors refused to give the placentas to the mothers, fearing they would eat them and spread disease. How should doctors react when acknowledging their patients’ cultural traditions could be hazardous to their health?
2. Although we have many translators today, do language barriers still play a role in improper treatments? “The Spirit Catches You and You Fall Down” translation of Qaug dab peg might not necessarily imply epilepsy to an unknowing person (for instance a person familiar with the Hmong language but not the disease).
3. During Lia’s initial hospital visit she was misdiagnosed. Is there a way we can avoid this in the future even with language barriers?
4. The Hmong people’s questions for the woman returning from the United States suggest a bad perception of American healthcare. How can we reverse poor perceptions concerning western medicine?
5. Dwight Conquergood’s efforts to integrate inoculation into the local culture proved effective in Ban Vinai. How can we apply methods like this to our healthcare system?

The questions sparked a discussion of where to begin when addressing the poor healthcare with which Lia was provided. Should the blame be placed on individual physicians or was it a systemic, intersectional failure on the part of the US healthcare system? On the one hand, doctors should have probably asked more questions and communicated more effectively, but the lack of translators and education on Hmong culture was probably more detrimental. We also discussed the methods Dwight Conquergood used in chapter four to spread awareness for canine inoculation in Ban Vinai. Some felt it was manipulative and coercive, while others regarded it as merely informative and engaging. I tend to agree with the latter because the Hmong were not forced in any way to inoculate their dogs. Overall, it was a productive discussion, but I would like to delve deeper into the subject of who should be blamed for Lia’s poor healthcare.

Response:

Throughout these first four chapters, I feel that a type of “war between cultures” is unfolding. Lia’s parents Foua and Nao Kao have strong Hmong roots and frequently opposed the American doctors’ medical treatments in favor of their own traditional medical practices. There are obvious systemic failures present in this situation such as the lack of translators and access to other nearby medical facilities for low-income families like the Lees. Problems like these may not play as large a role today as they did in the eighties, but cultural differences can certainly still have an impact on how patients are treated. Although it may be easy for someone reading Fadiman’s book to immediately point a finger at Lia’s doctors for her continual decline, it is difficult for me to hastily assign blame in this fashion. I believe it is crucial to view the issue from not only the Lee’s perspective, but also that of the doctors.

Later in the book, Fadiman recounts the harrowing events of the Lees’ escape from Laos and eventual arrival in the United States. With no money or resources, the Lees were reduced to living in a small apartment in Merced, California with virtually no furniture, essentially surviving off welfare checks. When I initially read that neither Foua nor Nao Kao worked to provide for their nine children, I was greatly troubled. Fadiman later explains, however, that the Lee’s were farmers back in Laos and the skills in which they were proficient were virtually useless in the US. Additionally, as I continued to ponder this, I realized that the language barrier would make them poor candidates for most career fields until they learned English, which Fadiman mentions they were attempting to do.

The Lee’s held their Hmong traditions and culture in very high regard, but they were also open to American medical practices. Although epilepsy is regarded as an honor in Hmong culture, Foua and Nao Kao were still concerned for their daughter’s health and took her to the hospital. Their idea of a proper treatment plan consisted of American medicine alongside Hmong Neeb, but the doctors were reluctant to implement this plan. Although some doctors probably were biased against the Hmong people and their medical practices, I feel that the primary reason for this reluctance was poor communication. The language barrier was the primary issue in this case, but I feel that poor communication still plagues the physician-patient relationship even today. How do we address this issue in the modern context though? Although I feel both parties should bear some responsibility for communicating effectively, I think the onus should lie with the doctor to ensure both parties fully understand one other. For example, a wide variety of circumstances such as immense stress, profound grief, or poor fluency in a language, as in the case of Lia’s parents, can all impact a patient’s ability to interact with their physician. Still, we can’t simply throw the doctor under the bus anytime something goes wrong. It is important to analyze this issue of miscommunication due to cultural differences from their perspective as well.

Starting at Lia’s birth, the doctors already went against Hmong tradition by incinerating her placenta, which was common practice in the United States. Although there was clearly a lack of communication, as in numerous other cases of Hmong mothers, Foua only wanted to bury the placentas. The doctors, however, were simply following their training and trying to prevent the spread of disease. In chapter three, the doctors had no idea Lia had had a seizure when her parents brought her in and therefore only diagnosed her with “early bronchiopneumonia or tracheobronchitis”. Is all of this simply because Lia’s doctors were bad at their jobs? In my opinion, no. They were taught in medical school to use American methods for treating diseases and were probably accustomed to patients who spoke English. It is difficult for me to blame the American doctors who were never educated on the traditions of foreign refugees. How can they be expected to know if they can’t ask the Hmong and no one tells them? I feel that the US government should have established a program to educate healthcare workers in Merced on the Hmong culture and hired translators if they wanted doctors to actually be able to serve this population. In short, I feel that the difficulties the Lees faced are primarily due to a systemic failure.

In conclusion, I believe that the first four chapters of The Spirit Catches You and You Fall Down, along with the rest of Fadiman’s compelling narrative, depict the tragic effects of a culture clash compromising the United States healthcare system. The doctor-patient relationship is at the core of medical care, and when it is impacted by unchecked cultural barriers, there can be devastating consequences. In my opinion, we must hold the healthcare system largely responsible instead of individual doctors and patients. Lia’s heartbreaking story should inspire us to make the necessary modifications to our healthcare system to ensure that cultural differences don’t get in the way of providing quality healthcare for every patient.

Works Cited

Fadiman, Anne. The Spirit Catches You and You Fall Down, Farrar, Strauss, and Giroux, 2012

Pharris Livingston

Professor Emerson

IDMD 101

26 October 2023

Unnecessary Medical Intervention and Treatment Errors

The topic was introduced to the class through three sources. The first was “When Evidence Says No, But Doctors Say Yes” by David Epstein. In this paper, Epstein describes the extremely prevalent yet relatively unknown issue of physicians performing medical interventions or prescribing drugs that have been proven to be harmful, ineffective, or inferior to other treatments.

The second source was “Medical Error, Malpractice And Complications: A Moral Geography” by David M. Zientek. This passage explains how recent research has shown that medicine has put a major emphasis on preventing system errors but not so much on actual human error. This could pose an unintended negative consequence of shifting attention from individual moral agency in untoward incidents. The third source was not referenced in the class discussion, and, for this reason, I see no utility in summarizing it.

I kicked off the discussion with a current healthcare conundrum that was introduced by Epstein. The question was as follows, “What do you believe is the correct balance between strict FDA Drug approval that ensures drug efficacy and safety and more casual FDA approval that allows patients to receive drugs sooner?” This question was met with a notable silence that I take as a good representation of the difficult decision that this question poses. The first comment made explained that it was difficult to hold any other view except supporting strict FDA approval because Epstein was so against loose FDA regulations. The class concluded that it came back to an argument about personal freedom. The individuals that supported loose FDA regulation did so on the grounds that if a patient decided that they were willing to bear the responsibility of any negative side effects of a drug, then they had the right to receive the drug. This argument was opposed three different ways. The first argued that because we would not fully understand the long-term side effects of drugs that are not well tested, they could have negative side effects that outweigh the benefit. I can agree with this point but not because the future negative side effects could outweigh the benefits. I can agree because this would mean that the patients would be incapable of providing informed consent as being informed of possible long-term effects would be impossible. This would mean that patients would be incapable of accurately deciding if they were willing to bear the responsibility of the negative side effects of experimental drugs when there is no way to know the severity of those side effects. The second was that loose regulations could jeopardize physician credibility because they would be the ones to prescribe treatments and, therefore, could share in the culpability of future complications. This point was quickly dismissed by the idea that physicians would not be held responsible, the patients would. I agree with this rebuttal. The last point argued that doctors are a beacon of authority and experts in their discipline; therefore, patients could not just receive a drug if they were willing to take a risk. The overall response to this point was that this denies patients the autonomy to make decisions about their own health. This was the end of this exchange as the issue came back to the core discussion, and everyone made their own conclusions based on what they valued more: personal autonomy or physician expertise.

My next question was asked as follows, “In the 2nd article by Zientek, it is stated that a healthy hospital environment encourages its physicians to speak up regarding their own mistakes so that further mistakes can be avoided. How do you believe that hospitals can foster this environment considering physicians are incentivized to keep their mistakes to themselves?” The class’ first reaction to this question was the suggestion that a hospital environment was largely dictated by respected authority figures; therefore, if they accepted accountability for their actions, then the whole hospital would. This argument was strongly supported by a student who admitted that there was a moment when working at a pharmacy where he or she thought they might have made a mistake, but because they respected their manager, was entirely open to discussing the error. After some investigating, it turned out that they were not at fault and the problem was fixed. I fully agree with the class regarding this discussion. Leading by example is an important aspect of any authority position, so if a certain environment is desired in hospitals, it is the responsibility of the hospital leaders to establish norms.

As this discussion reached a consensus I asked my third question based on a hypothetical described by Zientek. The question went as follows, “Zientek describes an anecdote in which a nurse accidentally hangs the wrong IV bag, but as a result of being overworked and bags not being clearly labeled. How much of the blame of this error do you believe lies with the nurse versus the system that perpetuated the error?” The first few points basically placed the entirety of the blame on the hospital system, which was supported by the fact that the bags were not labeled well. Initially, I did not subscribe to this idea. Even though the system definitely shares in the blame, the nurse did make a mistake. He or she should be checking the labels to IV bags carefully enough to avoid any kind of error; therefore, the nurse also shares culpability. I maintain this belief, but I fully agree with the idea that healthcare workers are people too. So, hospitals are obligated to help minimize mistakes. Poorly labeled IV bags are unacceptable. The class then began to discuss the reason that the nurse was overworked: a shortage of healthcare workers. The reasons the class listed for this shortage was the mistreatment of healthcare workers, the cost of education, and a lack of medical school and residency opportunities. This led Dr. Emerson to ask, “If overworked nurses are a systematic error, how do you fix systemic issues?” One student explained that if the entire staff of hospitals maintained accountability, then preventable action could be taken against systematic errors. This would be more effective than increased funding because these issues could not be solved by financial means. I do agree that money would not solve most medical systematic errors, but I also do not believe that money was ever even considered for a solution considering that hospitals have the money to solve problems if it is deemed necessary.

I had many takeaways from this discussion. The first was the idea that when deciding between strict and loose FDA drug regulations, the discussion comes down to one’s beliefs regarding the importance of personal autonomy or physician expertise. When debating this in the future, these two values should be the focus of the discussion. My second takeaway was that in order to foster an environment of accountability in medicine, it is the responsibility of authority figures to encourage accountability through example. My final takeaway was that hospitals are obligated to maintain systems that minimize gross error in the treatment of their patients, and if systematic error is involved in a mistake, the blame lies entirely with the system.

Works Cited

Epstein, David. “When Evidence Says No, but Doctors Say Yes.” ProPublica, Feb. 2017, www.propublica.org/article/when-evidence-says-no-but-doctors-say-yes. Accessed 10 October 2023.

Zientek, David M. “Medical Error, Malpractice and Complications: A Moral Geography.” HEC Forum, vol. 22, no. 2, 18 May 2010, pp. 145–157, https://doi.org/10.1007/s10730-010-9130-9. Accessed 10 October 2023.

Reading Summary

This week, we engaged with two readings and a video. The first reading, “The History of the Doctor-Patient Relationship” by Edward Shorter, delineates three periods: traditional, modern, and postmodern. The traditional era featured under-trained physicians practicing ineffective medicine and experiencing low status and financial struggles. The modern era saw advances in pathophysiology, including clinical examination, pathological anatomy, and microbiology. Despite few therapeutic improvements, the public image of doctors rose high due to doctors treating patients more as people and the view of doctors as scientists. The postmodern era witnessed substantial drug and pharmacology developments. Doctors were vigorously trained as scientists, making them treat patients less empathetically. Consequently, public image fell, exacerbated by media portrayal.

The second reading, “How Doctors Think” by Jerome Groopman, highlights diagnostic errors doctors can make, illustrated through personal examples. Groopman discussed three types of error: representativeness error, attribution error, and affective error.  Representativeness error stems from a thought process guided by prototypes, often blinding one to opposing possibilities. Attribution error involves attributing symptoms to the patient’s fault rather than underlying conditions. Affective error arises when placing excessive value on desired outcomes clouds judgment. Additionally, the video, “Surgical Resident Breaks Down 49 Medical Scenes From Film & TV | WIRED,” revealed how popular media can inaccurately (and accurately) depict medical procedures.

I originally prepared four questions: 

1. How do you interpret the doctor-as-a-demigod view? A good thing? Bad thing? In between?
2. This article was written in 1993. How do YOU BELIEVE general perception of doctors has changed (or not changed) today?
3. It seems easy to say that if a patient displays x, y, and z symptoms, then doctors should run x, y, z, and any further testing required to rule out all other possibilities (e.g. McKinley cardiac issues). Why, then, do doctors still make such emotional errors?
4. What is the balance between doctors showing compassion and care for their patients and doctors being scientific (both internally and externally)? (This was answered in another question.)

Questions were added to adjust to the flow of the discussion. 

1. How do you interpret the doctor-as-a-demigod view? A good thing? Bad thing? In between?

The consensus was that physicians should not be viewed as demigods, as it could lead to abuse of power and corrupt physicians. It could also put unrealistic expectations and thus unnecessary pressure on physicians. Whether or not physicians could be viewed as a benevolent or evil force, a core theme is a power imbalance over patients.

2. This article was written in 1993. How do YOU BELIEVE general perception of doctors has changed (or not changed) today?

Students believed that the perception of doctors has worsened over time. Factors like the rise of Urgent Care, Telehealth, and Zoom meetings have led to less personal interactions between doctors and patients. Although it would be ideal to take the time to assess every patient, classmates feel that it is hard to find a balance; the current system maximizes patient number and efficiency. Therefore, patients feel as though their doctors do not listen to them, causing patients to lose trust.

3. It seems easy to say that if a patient displays x, y, and z symptoms, then doctors should run x, y, z, and any further testing required to rule out all other possibilities (e.g. McKinley cardiac issues). Doctors are also aware of these errors. Why, then, do doctors still make such emotional errors?

Classmates discussed the initial judgments doctors make and the human tendency to stereotype.  Some believed that judgment was inevitable, but doctors may still maintain a professional and respectful appearance. Next, we debated whether liking a patient was necessary. While most argued no, some argued that even without open hostility, patients can sense how their doctors feel about them, which could result in patients feeling uncomfortable enough to leave out vital information. 

One classmate claimed that even if a criminal was their patient, they still need to treat them with the same respect they would treat other patients. Yet, others claimed that if a physician truly detested the patient, they should refer the patient to another physician and assess their own biases.

4. Do doctors have the moral permissibility to treat criminals differently?

The general opinion was yes — that criminals could be treated differently. Classmates focused on the idea of an initial judgment that dictated further opinions. Others opposed, claiming that we, as people, should strive to not judge others.

Two additional questions (“How does a person’s perceived race, sex, LGBTQ+, socioeconomic status, age, mental disorder, criminal history, etc. affect a doctor’s perception of them? Vice versa?” and “Should someone be held liable if a doctor makes an erroneous diagnosis or misdiagnosis that leads to the patient’s death or a severe health development?”) were not discussed due to time constraints.

Analysis & Conclusion

The overall discontent with physicians and the doctor-patient relationship today is concerning yet hopeful. Recognition of a problem suggests an effort to improve in the future. However, expectations of a display of care may be more difficult than it seems in a busy clinical setting. 

What is alarming, though, is the attitude that we cannot control judgments and a heavy emphasis on physician autonomy.  A physician should not refuse services based on race, ethnicity, gender, religion, sexual orientation, or based on any other prejudiced attitudes. Discrimination has no place in healthcare, and addressing these issues is crucial.

Another problem was that the conversation seemed to contradict itself when classmates pointed out that time was of the essence in the medical system and the dangers of giving physicians too much power. A patient must go through the trouble of scheduling an appointment usually weeks to months in advance, make time for it, cancel anything in conflict, travel to and from the location, and pay for the appointment. When a physician refuses a patient, diagnosis and treatment may be delayed several weeks or months. 

This brings up the idea of patient rights versus physician autonomy — in what situations does one trump the other? Perhaps in future discussions, we may address this. As for now, acknowledging diagnostic and care errors made by doctors and proposing ideas for improvement suggests a changing attitude among the future generation of physicians.

Material Summaries:

Hippocrates: The Physician summary

Hippocrates is discussing the preferred physical appearance of a physician. He must present himself as well-taken-care of. He must be fair, proper, and self-controlled, and he can’t be harsh or demeaning, or he will not establish rapport with the patient.

Hippocrates: The Oath summary

The oath is a statement of a physician that he will “do no harm” and always act in the best interest of the patient. A doctor must act dignified and respectful of all patients and must never speak of a patient’s confidential information to another. Interestingly, the oath mentions today’s controversial topics like abortion and physician-assisted suicide as completely prohibited.

Groopman: How Doctors Think Introduction summary

Throughout the introduction, Groopman tells the story of Anna Dodge, a 31-year-old woman who had seen doctor after doctor for years because they couldn’t figure out what was wrong with her. She had been diagnosed with anorexia and bulimia, and later irritable bowel syndrome, but even after increasing her daily calorie intake, she was getting worse. Finally, a new doctor named Dr. Falchuk came in and sat down with her, listening gently to her description of her condition in her words, and he diagnosed her with celiac disease.

Groopman believes the doctor-patient relationship to be created through trust. That trust is founded upon language, mannerisms, and actions. Groopman praised Dr. Falchuk for listening to Anna and letting her explain her symptoms herself with no judgment or wrongly constructed questions.

Groopman criticizes medical school teachings for making students learn the clinical decision tree, a closed, limited way of diagnosing patients’ conditions. He believes that doctors must learn to think outside the box more.

Discussion Questions:

• How much merit does the clinical decision tree have? How helpful is it in diagnosing patient conditions?
• Groopman’s book was published in 2007. Do you think there has been a change in the way doctors have been taught to interact with patients since then?
• Given the controversial medical topics discussed in today’s age, should the Hippocratic Oath be changed, or even done away with?
• In what ways could medical schools teach their students to think outside the box more?
• How much weight does physical appearance have in a patient’s first impression compared to mannerisms?
• What should be the most important step in establishing a trusting relationship between the doctor and the patient?

General Discussion in Response to Questions:

• How much merit does the clinical decision tree have? How helpful is it in diagnosing patient conditions?
  • Should be expounded upon
  • Discussion of topics in this class is binary, similar to the algorithm of the decision tree
  • Can become obsolete when effects on the patient aren’t necessarily biological
  • Helpful in some ways
    • Base understanding of diagnosing patients
    • Good building block to learn off of
    • Provide established method of structure to narrow down diseases
  • Only relying on the decision tree can miss things
    • Can be challenged by preconceptions and tunnel vision
  • Start with decision tree, then go from there
    • Definitely listen to the patient’s descriptions and experience
  • Decision tree must be continually reassessed throughout the patient questioning and treatment process
    • New information can render previous assumptions invalid
  • Decision tree can lead to confirmation bias
  • Decision tree helps administration, insurance cleanly categorize cases
  • Helps people who fit within the “normal” mold of a disease
  • Decision tree treats the condition rather than the patient
    • Makes the patient into a puzzle
    • Similar to a calculator with functions – inputs affect outputs
  • Should be expanded and changed to fit what the patient is saying
• Groopman’s book was published in 2007. Do you think there has been a change in the way doctors have been taught to interact with patients since then?
  • Med school is a classroom setting
    • Loses humanity
  • Primary care physician response has been pretty positive
    • Listen to patients
  • Specialists take the decision tree more into account
    • Natural, given that they are specialists and don’t know the patient as well as primary care
  • Bedside manner can’t always be taught
    • Experience can play a large factor in bedside manner
  • Today, people value quick, easy service instead of quality face-to-face that might take longer
    • Telehealth has exacerbated it
  • Physicians must be able to accept when they’re wrong and question their biases and judgment
    • Can be affected by stereotypes, implicit bias
  • Doctors need to trust the patient more
    • Cynicism is becoming more prevalent
    • Should be skeptic, not distrustful
• Given the controversial medical topics discussed in today’s age, should the Hippocratic Oath be changed, or even done away with?
  • Most medical students don’t actually say the original Oath
    • Have changed it to match today’s social values
    • Has become a list of things to do or not to do, not necessarily the original
  • Should be changed to fit the times
  • There are values in the Hippocratic Oath that are valuable, but not because they’re in the Hippocratic Oath
  • Medical schools should go back to lower tuition
    • Stipulated in the Hippocratic Oath
    • High tuition counter-incentivizes students so that they avoid medical school or accept programs of less prestige and learning
• In what ways could medical schools teach their students to think outside the box more?
  • Did not get to
• How much weight does physical appearance have in a patient’s first impression compared to mannerisms?
  • White Coat Syndrome
    • Patients’ blood pressure increases when they see people wear white coats

• • • • Authority figure makes them stressed out

• • Some people value white coats and suits more
    • Looks more professional
  • Every patient population is different and views doctors differently
    • Physical appearance matters for what type of patient they’re seeing
    • Know the audience
  • How you act is also important
    • Okay to have a personality and laugh, but always remain professional
    • Always take patients seriously
  • Must be conscious of the agenda people have
    • Emotion shouldn’t be ignored
• What should be the most important step in establishing a trusting relationship between the doctor and the patient?
  • Did not get to

Discussion Response:

What I took away from this discussion is that America as a whole is moving towards a quicker, more efficient society at the expense of personal relationships. This is a big problem; the core of medicine is to definitively help someone, and that cannot be completely accomplished without forming interpersonal connections with the patient. However, if bedside manner is falling out of curriculums in undergraduate and medical school, the only way to develop it is through years of experience. As the name suggests, it takes a long time to build that up, and a doctor could see countless patients before a satisfactory, successful bedside manner is developed.

That is why classes like IDMD 101 are so beneficial; not only does it encourage future physicians to think for themselves and create their own opinions, but it also teaches the value of viewing the patient as a person and not just an amalgamation of statistics. Medicine is neither linear nor clear-cut, and the efficiency that the medical field values tries to circumvent that by ignoring bedside manner and embracing concepts like the decision tree.

While such concepts are useful in many situations, there should never be one concept or process that is the end-all-be-all of a patient’s treatment plan. Just as a patient should never be construed as a simple statistic, or another tick on a list of “patients helped today,” physicians should remember that there is never a perfect way to examine and diagnose a patient. It is imperative that physicians learn to adapt to and account for outlying situations like Anna Dodge’s, because looking at a new problem from a conventional stance might not reveal everything that is happening with the patient, and therefore the physician can’t make the most informed estimates on the patient’s diagnosis and/or treatment.

Brief Summary:

Giesbrecht argues that differences in social and personal factors can have significant impacts to one’s life and health, but research only tends to group people into general populations, which can cause important health data to get lost or overlooked. Other names for this are diversity based analysis, which focuses on differences between and within groups and how that affects life, and intersectionality, which is about relating two or more inequalities as they are experienced simultaneously. Sex, referring to anatomy, and gender, referring to personalities, social constructs, or behaviors, are the main categories that research typically uses, but there are also other social determinants of health like socioeconomic status, education, sexual orientation, race, ethnicity, and more. Recognizing and acknowledging the diversity of individuals can help to rectify inequity in health spheres, as treating an entire population equally is ineffective due to the unique lived experiences within smaller populations.

Hausman argues that egalitarians in regards to social policy are currently using a form of data collection about health inequalities that is ineffective, because they are unable to accurately find whether there is an injustice at hand that needs resolving. Having a health inequality can impact overall life prospects, and therefore be unjust, but not all inequalities result in injustice, and that’s where the lines get blurry. Quality adjusted life years of a certain demographic can help egalitarians pinpoint which groups of people tend to suffer more health issues, and therefore can lead to inferences about which populations have more injustices–but this system of using QALY isn’t that good because it leaves out whether the health inequality is compensable. When a health inequality is incompensable, it can be said that there is an injustice because that person is on an uneven playing field against the rest of society. Finally, Hausman gives an example for why basing injustice and general inequality on health inequality is in poor judgement: one can be poor but healthy, while another is wealthy but unhealthy. There are many inequalities between these two people, but going off of health would proclaim that there is little to none.

Discussion Questions:

• When would generalities about health be permissible, if at all?

• Is QALY a good way to measure inequality, and therefore injustice?

• When would an inequality constitute an injustice? 

• If a health inequality was compensable, would the person still face an overall (life prospects) inequality?

• Health inequalities differ throughout a life, so would we/how would we divide life into stages/age groups?

• Do SDH factors or sex/gender impact health more?

Summary of Discussion:

For question 1, the majority of the class agreed that generalities are permissible but only in certain amounts and for specific circumstances. For example, in the case of a 40 year old and an 80 year old with the same condition, it can be assumed that the 40 year old is better off because younger patients are generally healthier. Another perspective raised is that generalities are only justified when multiple ones are layered together or used as building blocks to help define the patient, rather than just using one big generality and fitting the patient in that box. Similarly, it was said that while generalities can help on a larger scale, it’s not as useful when dealing with individuals as everyone is different. A shared sentiment within the class was that generalities are permissible when not much is known about the patient, such as when first meeting them or having an unconscious patient. One person brought up the idea that generalities can be used in combination with statistics such as certain populations generally being more at risk for conditions, but the generality shouldn’t be taken as 100% certainty. On the other hand, generalities also shouldn’t be used to completely close out the possibility of a patient having a condition just because they aren’t in the population most at risk.

Question 2 opened up with people saying that the idea that someone can live a full year of perfect health is flawed, so QALY is inherently impaired. Even if someone were to not be in perfect health, it usually isn’t so bad that it would affect quality of life significantly like QALY suggests. It was brought up that a lot of health issues arise from treatable problems, so would it be correct to call something like a diabetic purposely eating sugar an injustice or just a bad choice? The class agreed that QALY is not appropriate or applicable to use because there is a diverse range of health issues while QALY is vague and incalculable. “Quality” is a generality because everyone has a different benchmark for what “good quality” means to them–according to QALY, disabled people are suffering, even when they themselves may be fully functional and happy. On a larger scale, like WHO reports, QALY is helpful, though not perfect, but when it comes down to individuals and their life choices, like a cancer patient rejecting treatment to be with family, QALY is not helpful.

The class began question 3 by defining injustice as a person having no control over their circumstances and the differences in their life cannot be rectified. Alternatively, if a person is able to do something about their situation it would be called an inequality. Inequalities and injustices are not the same, with an example being given of not having money to buy a salad vs. not being allowed to buy the salad (regardless of funds available). Injustices are systemic problems that aren’t within the scope of a physician because it involves greater social injustices, though those societal problems are a leading cause of health injustices. The conversation at this point then pivoted to talking about intersectionality and how it’s not very useful because it becomes so specific, and that intersectionality, though it intends to be less vague, it’s still susceptible to generalities about people with X and Y because multiple people can share X and Y but still be different, which just goes back to grouping people.

Response: 

Based on the discussion, I realized that a lot of reporting methods about health are very general, but that there’s no concrete way to rectify the problem. Adding onto the fact that if it was difficult for all people in our class to agree on definitions and treatments of inequalities, it would be near-impossible to find and execute a national or worldwide standard for what is acceptable in healthcare. I also noticed from the discussion that the class puts a lot of value on individual and patient-centered care, and while I also agree that it’s important to focus on each patient, I believe a paradox is at hand. The more a physician spends time giving top quality care to a patient, the busier a physician will be, leading to longer wait times before a patient will be attended to, resulting in lower care satisfaction. I bring this up to make the point that no physician and no treatment plan will ever be perfect, so instead of trying to make guidelines for what is or is not a generality, quality of life, or an injustice we should let doctors find out what works best for them and the community they serve.

Summary:

In The Atlantic article “How Canada’s Assisted-Suicide Law Went Wrong,” David Brooks explores the ramifications of extreme liberalism on healthcare and individuals by examining Canada’s MAID law. Liberalism celebrates freedom of choice, but this freedom can turn detrimental and contribute to societal breakdown when taken to the extreme. In 2016, Canada’s medical assisted in dying (MAID) law legalized physician-assisted death. The original qualifications for assisted dying were well-defined and reasonable, but in recent years, the qualifications have relaxed and the range of qualified people has increased and expanded. In autonomy-based liberalism, where individual autonomy rules above all, people become isolated and prone to suicide. Instead of autonomy-based liberalism, our society’s perspective should move towards gift-based liberalism in which each person is a receiver of gifts, and has the responsibility to recognize those gifts, use them to benefit the community, and pass them along to future generations. With gifts-based liberalism, people will find deeper purpose and meaning in life. Policymakers should value the good of the people over the will of the people.

Connections to Medical Philosophy:

Brooks’ article touches on several of the philosophical concepts described in Jacob Stegenga’s “Care and Cure” book, including what it means to be healthy (Chapter 1), the definition of disease (Chapter 2), and the definition of death and ethics of killing (Chapter 3).

According to chapter 1, the positive health view holds that being healthy involves something beyond mere freedom from disease; a patient’s overall well-being must be taken into account, which includes having meaningful relationships, achieving life goals, and being satisfied with life. A person may look physically healthy on the outside, but could be overall unhealthy if the person struggles with life circumstances or mental health. Physicians and policymakers need to be aware of the positive health view to help prevent situations like in Canada, where people see assisted suicide as an escape from misery and release of suffering. The Atlantic article revealed that some people cite poverty or housing uncertainty as the main reason for seeking assisted suicide. The positive health view would argue that people who struggle with poverty or housing uncertainty are unhealthy because they are not satisfied with their life, nor achieving their life goals. Patients who are not medically future but seek assisted suicide as a release from distressing life circumstances are looking for purpose in life.

In chapter 2, the definition of disease that relates the most to assisted suicide is normativism, which contends that diseases are disvalued states, and a person with that condition is harmed by it. Normativism holds that disease is directly related to values. Therefore, from the normativism perspective, being disabled is a disvalued state, and people with disabilities are less than people without disabilities. When MAID was created, administrators conformed to the idea that some lives are less valuable than others, in which people with disabilities have less fulfilling and worse lives than people without disabilities. However, people who find value and purpose in their lives can feel happy and fulfilled, despite their disabilities. In The Atlantic article, historian Wilfred McClay’s mother remarked that if she ever was left unable to read, write, or speak, then her life should not be prolonged because there would be no point in living. A couple years later, his mother suffered a near-fatal stroke, and she was unable to speak. Contrary to her statement a few years earlier, his mother found meaning in life: she became a warmer, more affectionate, and more generous person who communicated through gestures, facial expressions, and loved her grandchildren. Spending time with her family brought her joy in life, and her life was not any less full. Based on the normativism definition of disease, McClay’s mother was not diseased because she did not feel harmed by it and she found meaning in being a loving mother and grandmother.

Moving onto the topic of death in chapter 3, the concept of personhood applies to the ethics of assisted suicide. Personhood is a status in which a person has moral properties and cognitive capacities, like the capacity of consciousness. Personhood differs from biological death, which is the cessation of functioning of the physical body. From the personhood perspective, death is the loss of a soul and losing the capacity of consciousness. A person in a permanent vegetative state is alive as a biological organism, but dead in the sense of personhood with loss of consciousness and moral properties. In Canada’s MAID law, the requirement that natural death must be “reasonably foreseeable” was lifted in 2021. In the article, Brooks names patients who were granted access to assisted suicide even though death was not reasonably foreseeable, including 61-year-old Alan who had hearing loss and history of seizures, 37-year-old Tyler who was physically healthy but suffered from PTSD and schizoaffective disorder, and 23-year-old Kiano who had diabetes and lost vision in one eye. All three of these patients retained their personhood, but decided for themselves that life was not worth living anymore. When applying the personhood perspective to assisted suicide, administering lethal doses to these three cases would not be ethical because there was no death of personhood.

Applications:

Featured in a multi-platform, thought-provoking magazine, “How Canada’s Assisted-Suicide Law Went Wrong” is an opinion piece that harshly criticizes the implications of Canada’s MAID law. After reading this article, the average reader would be outraged by the liberalism and looseness of Canada’s MAID law and want to advocate for stricter qualifications and support groups to help people find meaning for life. However, there is a disconnect between the popular production of medical knowledge in the media, and how medical knowledge is discovered and produced in research. Although well-written, this article was opinion-based and did not thoroughly examine each qualification in the MAID law, choosing to focus more on how people who did not fit the original criteria were being granted access to assisted suicide. The article also did not explore whether people who cited poverty and housing uncertainty as reasons to seek assisted suicide actually got their request granted.

News media can exaggerate and omit parts that do not tell the readers the entire story. When people consume medical knowledge from news media instead of research journals, they might emerge with a perspective that is not completely accurate. To navigate an atmosphere in which patients are consuming medical information through the news, public health advocates and healthcare workers should be responsible for communicating both sides of medical issues and should be well-versed in how medical information is portrayed in the media compared to in research. When patients come to practitioners with misinformation about medications or treatment plans, practitioners should respond in a thoughtful and respectful way that clears up any misconceptions that the patient has.

References

Brooks, D. (2023, May 19). Canada legalized assisted suicide-and exposed the limits of liberalism. The Atlantic. https://www.theatlantic.com/magazine/archive/2023/06/canada-legalized-medical-assisted-suicide-euthanasia-death-maid/673790/

Kaitlin Deans

Dr. Geoffrey Emerson

IDMD 101-004

6 Oct 2023

Physician-Assisted Suicide in Canada

       In 2016, Canada implemented a national law that prohibits physicians from suggesting Medical Assistance in Dying (MAID) to patients that only suffer from mental illness. Currently, the rule stipulates that the only patients eligible for MAID are those who are older than 18 and have a serious and incurable condition that will lead to death. However, a physician at a Vancouver hospital recently offered MAID to a patient suffering from chronic depression and suicidal thoughts. I was unable to find the original Canadian report, but there is no mention of the patient having any physical ailment.

This means that a physician in Vancouver broke Canadian law by offering assisted suicide to a patient who was suffering purely from a psychiatric diagnosis. This could set a precedent of physicians ignoring the law in order to give a treatment that may or may not be right morally or legally. Not only that, but it could even harm the patient further by giving them a sense of hopelessness that a professional believes it is futile to help cure them.

This touches on informed consent, because the law states that in Canada, patients who only have a psychological problem with no physical underlying condition are ineligible for physician-assisted suicide. Not only does offering the treatment to an ineligible patient make them think that they are eligible, but patients who are receiving this as an option (psychiatric patients with no terminal physical condition) are not generally considered mentally sound enough to make this kind of decision for themselves.

It also touches on medical futility, because only patients who have a terminal physical condition may be offered the treatment. This better defines what Canada believes is a medically futile case; patients with psychiatric disorders, even those that are severe, are not considered futile and therefore cannot receive the treatment.

A patient could misconstrue this as the physician thinking they are a medically futile patient, which could lead to a hopeless mindset due to the idea that a so-called expert in health does not believe they will get better. If a medical professional that society tends to idolize doesn’t believe a patient will get better, then why should they believe they will? I realize that isn’t the case with every patient, but there are those who would give up hope based on everyone around them giving up too. This could push them to attempt to end their own life through unsafe means, which is why many doctors discuss the option with the family first, before bringing it up to the patient.

This could also lead to misinformed consent because the patient is now considering a futile option rather than the viable options they actually have. Once someone in the hospital realizes the patient’s situation and that this is the treatment being offered for that situation, it will no longer be on the table. Not only is a doctor projecting their view of futility on a patient and thus affecting the outcome of their treatment considered paternalism, but it can also fall under lying to a patient because they are telling them of an option that they can’t actually use.

More often than not, those two seem to go hand in hand. If a doctor wants to override a patient’s free choice, whether they have a sound mind or not, it is very easy for the doctor to misrepresent statistics or even omit information altogether to influence a patient’s decision towards what the doctor wants them to do.

From a patient’s perspective, offering this treatment to a patient and their subsequent acceptance or denial of the treatment would depend largely on their personal beliefs, both surrounding the treatment itself and the law. Some would refuse to accept the treatment on religious grounds, or they would refuse the right of a doctor to give it in the first place. Some would accept the treatment, especially if they have planned it for a while (as in the case of someone with progressive illness). Finally, though it seems paradoxical and is likely very uncommon, I believe that it is possible for patients to refuse the notion that a doctor should offer it, but since they are offering it accept the treatment anyways. Overall, if they are of sound mind, the doctor must accept their beliefs and choice, otherwise they would be engaging in paternalism.

The average public reader’s response to this would be dependent on their beliefs. They could lose trust in the medical field for giving patients a treatment that they do not believe in, or they could be perfectly okay with the treatment because they agree with the practice. Furthermore, if a patient is aware of the law surrounding MAID, they might lose trust in their doctor because they would see the doctor ignoring the law to advise them in care that they can’t receive. If a patient is unaware of this law, depending on the severity of a patient’s psychological state, they still cannot make an informed decision on this, and this treatment could hurt them in the long run. This brings up a different legal issue in not gaining informed consent before treatment, which could lead to lawsuits and loss of license.

As I am discussing the average reader, I should clarify my opinion on the subject, and how my opinion and that of a reader might differ. As far as I am concerned, I believe that since there is little understanding of psychological disorders and how to truly cure them, Canada’s approach is logical, and I can understand it. For personal and religious reasons, I would never give MAID as a treatment, but I would still discuss it with the patient and refer them to a physician who would give it to them, assuming the patient is of sound mind and has discussed this at length with me and the other medical professionals involved in their care.

This article could help close the expertise gap between patients and doctors because it emphasizes how most patients know their own bodies better than a doctor does. This is instinctive to most mentally sound patients, and it has even been a cause of debate between doctors and individual patients in a wide variety of settings. In most cases, if a patient is mentally sound, they are the ones to make the ultimate decision about treatment, not the doctor. If the doctor believes the patient not to be of sound mind, then the patient cannot make an informed decision and it is decided that the doctor (in the absence of family and emergency contacts) is in a better position to make that decision for them. This, I believe, is Canada’s reasoning behind imposing such a law that only patients with futile physical ailments can even be considered for the treatment.

Works Cited

Kornick, Lindsay. “Vancouver hospital discusses ‘medical assistance in dying’ treatment to suicidal patient.” Fox News, https://www.foxnews.com/media/vancouver-hospital-discusses-medical-assistance-dying-treatment-suicidal-patient. Accessed 6 Oct 2023.

Philip C. Brutkiewicz

Dr. Emerson

IDMD 101

29 September 2023

Physician Assisted Death

What is death? When do we truly die? These are the main questions brought to us in the first reading of the day. Many define death as the permanent end of biological functioning of an organism, or organismic death. This is contrasted with the death of a person, which is the irreversible loss of all functions of the brain and consciousness. These trains of thought lead us into questions about abortion, euthanasia, and the withdrawal of life support. Death Dualism combines both of these ideas, stating that death is both organismic and consciousness-based. In the Quill article, Dr. Quill indirectly “helps” his patient, Diane, with terminal cancer commit suicide by providing her with a high dose of sleeping pills which he knows she could use to kill herself. His patient, Diane, has leukemia but decides she doesn’t want treatment as she wants self control and dignity for the remainder of her life. Just as in Chapter 3, the example of Diane brings up the debate of is helping kill another person ethical? Should Quill be punished for assisting in a suicide of an already “dead” person? These are all questions that the article brings to the surface for discussion.

In class that day, after going over the summary of the readings, the class was presented with discussion questions. These included:

Kurt Cobain, the lead member of the band Nirvana, committed suicide at age 27, in the prime of his career. However, Cobain was suffering from depression and a heroin addiction. Was Cobain already dying before he took his own life? Does his situation deserve a different view than that of Diane, since Cobain’s ailment was more mental and Diane’s was physical? (different models of medicine)

Was Dr. Quill right in his decision to supply Diane with sleeping pills he knew she could take her life with (and did), letting Diane go out her own way even if it went against the Hippocratic Oath?

We begin the discussion with the first question, to which the class agrees, to various extents, that Cobain was not already dead. Cobain, even though he was in a horrible mental state, still had the power to get himself out. Switching from Cobain to Diane, Noah has no problem with Diane’s doctor helping take her life, but says that Quill should have justified his situation to law enforcement instead of lying and blaming her death on leukemia.  Diane was going to commit suicide anyway so it was best in a safe and controlled manner. Victoria says that Quill was right in the end as he saved the family from trauma. Too often we associate legality with morality, and covering it up was what the patient wanted. Kaitlin objects, saying that if Quill truly believed that what he died was right he wouldn’t have covered it up. The class agrees that Cobain and Diane’s issues were out of control, but they were only severely hindered, not dead. Nick believes that the medical professionals and patients both cannot really define personhood, only biological death. Dr. Emerson argues that Cobain’s situation has a different stigma because he was young when he died, even though addicts are always in recovery and never “normal” again. It is really difficult to pin down when a situation is medically futile. Micaela believes that one would be dead if they were living like Diane, barely able to function before dying of cancer in weeks. Alejandro is wary of this, as he thinks describing someone “dead” while they are still conscious could lead to a slippery slope where doctors are free to “pull the plug” for faulty reasons. Doctors are supposed to continue life, not end it.

The discussion then shifted to views on death and whether it is good or bad? Is it something to be excited for, with the hope of heaven/paradise? Sophia says that death is not black and white and we should rely on patients’ own opinions for themselves. Kaitlyn agrees, saying that some people religiously think that death is good because of hope for heaven. Nick believes that wanting death is not the same as wanting heaven. Noah believes that medicine needs to be personalized, just as finance portfolios are. Dr. Emerson agrees, saying death can change its value based on the situation.

After this discussion, I realized that the death of an organism is more useful than the death of a person. With the death of an organism, life is officially over, and physicians can act as such. However, personhood is more murky, with different members of society arguing loss of personhood at different stages of suffering. If society was to use the personhood model over the organismic model, it could lead to a slippery slope, which is worrisome. Doctors may abuse their power, and declare someone dead as a person too soon, especially members of society not deemed “useful”, such as the homeless or the extremely poor. These doctors may take these suffering members of society, and instead of helping them get as close to normal functioning, decide that their life does not have value and that they are better off dead. This is pure eugenics, artificially altering the genetic pool of the population, which has been rightly discouraged for almost a century but is starting to come back.

Personalized medicine is needed. As Noah put it, we already personalize finances, so why not personalize our livelihood and our health? Just because one human may be lost as a person does not mean another is in the same boat, even if they have the same health statistics. While Diane may have been “dead” as a person since she was ailing and about to die, another person might be excited to live the rest of their life, no matter the condition or duration. We should not make the same decisions on everyone, we must have diversity-based approaches instead of a one-size-fits-all approach.

This discussion confronts the debate of abortion. America has long been divided over the issue, whether fifty years ago with Roe v. Wade or the recent ruling in favor of state’s rights. Biologically, the unborn fetus is alive, as it has a pulse and is a living organism. However, early on, the fetus has yet to develop consciousness, which supporters of personhood can say proves that an abortion is not murder. In the early stages of pregnancy, I believe that the collection of cells is not yet a person, so an abortion is ok. However, in the latter stages of pregnancy, the child starts to develop some mental abilities. At this stage, I do not support physician-assisted abortions as it starts to become murder.

Through the readings and discussion, the class and I gained a better understanding of how we identify death, as well as when physicians should intervene. Some physicians, such as Quill, even intervene against the Hippocratic Oath if they think that it is the right decision. Doctors are taught to preserve life, not to end it, but if a situation is bound to happen, the doctor may act to make the situation as smooth as possible. Nothing is black and white, and death is no exception.

Micaela Bravo

Dr. Emerson

IDMD 101

October 10, 2023

Half the Population, Half as Respected

Source Summary:

It is being found in research that women are statistically less likely to be taken seriously in medical settings compared to men complaining of the same ailments or showing the same symptoms. Due to the fact that women are more sensitive to pain and more expressive than their male counterparts, a lot of doctors–especially male ones–take their pain as an overexaggeration and lead to severe issues like women being 25% less likely to be given pain meds for the same affliction as a man. Many women have failed to even get past the diagnoses stage, as a significant amount have stepped forward with similar stories about their doctors not listening to them, insisting on not running tests, and some were even sent to psychiatrists for an illness that, when finally meeting a competent doctor, was found to be a severe disease of the body like cancer or a tumor.

Significance of the Phenomenon:

When leaving the doctor’s office, no one should ever feel worse than when they came in, yet somehow a woman was “told ‘shut up’ by a nurse because [she] was screaming too loud while [she] was in pain” (Bever). Empathy is a monumental part of healthcare and should be used in every patient interaction because creating a safe space where they feel heard can mutually benefit both physician and patient. Rather than the doctor having to read the mind of a closed-off patient in order to have enough information to make a diagnoses and begin treatment, it would be much easier if they just allowed the patient to feel they can share things without feeling judged or invalidated, leading to more information that may be relevant to their healthcare plan. 

Paying attention to a patient can also avoid situations where their physical condition gets to a point of no return, like when a woman was screaming in agony during a labor where she was supposed to be getting epidural, but after multiple times of her healthcare team dismissing her pain and assuring she was getting the max dose, it was found out that the epidural slipped out which led to needing an emergency C-section. An entire room of medical professionals failed her. Had they listened, really listened, to what she was telling them, that she could feel everything and was in severe pain, they would’ve realized their mistake before her body gave out, which in the end costed the medical team more time and effort and the woman more money than originally needed. 

Additionally, being empathetic means to not discredit someone based on their appearance, but “research found that half of white med students and residents were more likely to underestimate black people’s pain,” leading to situations like a black woman with a chronic illness needing to change into her “Sunday best” in order to not be prejudiced or portrayed “as a drug seeker” (Bever). To immediately cast-off the pains of a human being just for wearing more worn-out clothes, or for having darker skin, or for being a woman is terrible and should not be as common as it is. 

Yes, in more recent times there have been steps forward in understanding female experiences of pain, but one would think “recent times” refers to the past hundred years. It was only in 2016 that the National Institutes of Health required most medical research to consider sex as a biological variable. Only 7 years ago. Half of the world population is female, and yet only 43% of medical students said their curriculum taught sex and gender differenes in medicine. Being taught to be understanding of people’s differences is surprisingly not as present in medical spheres as it should be. It all comes back to having empathy and being able to truly listen to patients when they keep coming back to their physician in indescribable agony. “[Empathy is] not enough for someone to have a sympathetic manner or use a caring tone,” as a doctor must actually take the time to listen and understand what their patient is going through (Jamison). Women may be more sensitive to pain, but that does not negate the fact that they are still feeling pain, and should not be cast away and told “it was all in [their] head” (Bever). 

A worse act though, more than not properly treating a patient, is to refuse to even run tests when asked multiple times by a patient with severe symptoms. If a patient has reasonable suspicion that they are ill and has no qualms with any risks involved in the process of running an exam, they should not be turned away because the physician thinks the patient is overexaggerating their condition. In other words: “you treat the pain that the patient has, not the pain that you think the patient should have” (Bever). It is wrong to decide that a patient is not suffering severely enough to have a severe disease, and keep them from proper diagnoses and treatment. Exams may also be refused due to paternalism and the doctor worrying about the patient’s well-being if they receive either a false negative or positive, and though this case is better than the ignorance case, it is still not right. 

The Effect:

The terrible stories of women who went through years of being denied proper medical care having been published through a massive publication such as The Washington Post is bound to make waves. Women with similar experiences can read those of other women in the submission board of the article and find that they are not alone, and they are not crazy. A lot of doctors chalk up female pain to be hormones, dramatization, mental illness, or a combination of the three, when in reality the patients who go to health offices seeking treatment or answers for their ailments are valid concerns that should be respected as such. After experiencing being shut-out by the person who is supposedly there to help you, many women “start to doubt [themselves]” and may be less averse to going back to seek medical attention until the pain becomes “unbearable,” and by then their illness may have permanent effects. Women should take back the reigns as “the owner of [their] health” and “go with their gut” when they feel something is wrong, and “if [their] provider does not appear to be listening to [them] or believing what [they’re] saying,” instead of feeling like their concerns are unimportant, they should get “a new provider” (Bever).

Works Cited

Bever, Lindsey. “From Heart Disease to Iuds: How Doctors Dismiss Women’s Pain.” The Washington Post, WP Company, 13 Dec. 2022, www.washingtonpost.com/wellness/interactive/2022/women-pain-gender-bias-doctors/. 

Jamison, Leslie. “Empathy Exams.” Https://Alabama.App.Box.Com/s/Kukl2jf235eikdd5x8tjcgq2tuot5ejk, Box.

This American Life: Use Only as Directed

            In this podcast, reporters analyze the history of Tylenol and its active ingredient: Acetaminophen. Though invented in the fifties, Tylenol became most popular in the seventies due to its lack of side effects when compared with competitors. Specifically following the 80s “Aspirin Wars” Tylenol fought in advertising to become known as the safest pain medication, , even though studies published since 1975 showed that Acetaminophen is seriously linked to liver failure. As more and more “accidental overdoses” were reported, calculations began to estimate that the difference between a safe and potentially deadly dose could be as little as an extra 2 extra-strength Tylenol pills a day over the recommended dosage. This problem is further compounded by the resistance of the McNeil’s companies’ resistance to address root issues, such as labeling of proper warnings of Acetaminophen usage, and the FDA’s reluctance to pass restrictions on the company. (Glass, 2013).

The issues the This American Life podcast brings up raises concerns over the ways in which pharmaceuticals act as businesses and how these effects general safety of medication. Due to the financial motivation to produce medicine with few side effects and good outcomes, some companies may feel the need to skew statistical reporting. This is partially examined in Chapter nine of Stegenga’s book: Care and Cure, which focuses on the statistics of medical reports and the extent to which data can be skewed based on the way the results are presented. It asks the question as to how this data can be applied to real life and the necessity of an impartial analysis (Stegenga, 2018). In an ideal world, every study would be conducted with as little bias as possible, but this article credits many of the “studies” that found Tylenol to be the safest drug, as being funded by the McNeil’s own company. McNeil argued in the court cases surrounding accidental overdoses that these trial studies were able to make this conclusion as the company possessed information that the governmentally funded trials run by the CDC did not. They pushed the idea that the lack of certain (unspecified) information led to a drastic overestimate of the number of accidental deaths, and even argued that most of these overdoses could be attributed to suicide (Glass, 2013). Stegenga’s article shows the possibility of such an occurrence, especially if the sample of cases used by the CDC were not truly representative of the population. But though it can never be said with complete certainty that the numbers released by the CDC on Acetaminophen are accurate, the greater possibility that the percentage of accidental overdoses are even near the rate reported is extremely troubling. It brings into question exactly what information should be required to be displayed on warning labels, to enable consumers to make decisions based on informed consent.

Without the proper wording and information properly displayed, the consumer of the product does not have the proper information to choose whether to use the good. A research article, Millum and Bromwich, clarifies this scenario through defining different perceptions of informed consent as well as what should be required for a subject to give informed consent. They argue that in order to fully assent to treatment, patients must understand “(1) that [they are] giving consent; (2) how to exercise [their] right to give or refuse consent; and (3) to what [they are] being asked to consent” (Millum & Bromwich, 2021). In the absence of a proper warning label patients cannot give informed consent to treatment using the medication due to the third requirement, under which it is necessary that the patient understands the risks of taking the medication. Thus, the sole way in which the company can ethically disperse medicine is if they oblige the CDC’s recommendation of the warning label’s wording. Though by the time the podcast was published the McNeil Company had already placed a proper warning label on their product, it took them forty years after the CDC’s report highly recommended the change for them to do so (Glass, 2013).

According to the podcast, a large reason behind this decision was the impact that such a statement would have on the public view of Tylenol. If the media picked up a story on the potential risk of liver failure while taking the advertised “safest pain medication on the market”, there would likely be grave implications for the company’s future. It became apparent that others recognized this to be true as well, as a competing brand once tried to use the CDC’s findings in an ad against taking Tylenol (Glass, 2013). The power displayed by this single ad shows how much weight news media carries, especially in the present day. It is often the main source, if not the only source, of information, for the general public. What they chose to focus on in a report or story has the potential power to sway or inform the nation. If the medical community was able to establish a good relationship with news media, the nation could be one step closer to closing the expertise gap between physicians and patients. This would allow for more cohesive communication and trust between the two, as well as limit unnecessary case numbers in overcrowded emergency rooms.

In application to the Tylenol controversy, when listening to this podcast the average public reader might begin to question their own use of over-the-counter medication, especially those that contain acetaminophen. If they chose to continue taking the medication, they will be able to do so, well informed of potential risks and benefits to taking acetaminophen products. This could lead to a dramatic decrease in accidental overdosing on over-the-counter drugs. In addition, listening to the risks of just one medication could open conversation between patients and doctors about other prescriptions, and conclude with the patient being able to fulfill requirements for the use of informed consent. Thus, the media, which in this instance exacerbated issues with pharmaceutical company disclosure, also poses the ability to change the gap of information between doctors and patients.

Sources

Glass, I. (Host). (2013, September 20). Use Only as Directed (No. 505) [Audio podcast episode]. In This American Life. Serial Productions. https://www.thisamericanlife.org/505/use-only-as-directed

Millum, J., & Bromwich, D. (2021). Informed consent: What must be disclosed and what must be understood? American Journal of Bioethics, 21(5), 46–58. https://doi.org/10.1080/15265161.2020.1863511

Stegenga, J. (2018). Care & cure: An Introduction to Philosophy of Medicine. University of Chicago Press.