Sufficient Scruples

Bioethics, healthcare policy, and related issues.

March 30, 2011

“Appropriate” Treatments: Categorical, or Situational?

by @ 1:32 PM. Filed under Access to Healthcare, Autonomy, Disability Issues, General, Healthcare Politics, Provider Roles, Theory

There’s a provocative post over at the excellent KevinMD Web site:

Overeating is a behavioral problem, not a surgical one

This may seem to be a statement of the obvious, but the solution to a behavioral problem is not surgery. Overeating is not a surgical problem — it is a behavioral one. The problem is not because the stomach is too big and needs to be made smaller. It is a function of how much food is put into the stomach. Surgical “solutions” should be the absolute last resort measure.

The letter – from an Australian physician who touts himself on the Web as a “DIY health” guru – goes on to make a number of good points about bariatric surgery (mostly stomach-banding), couched in terms of clinical efficacy and relative risk: it does not work for everyone; the campaign to expand the qualifying criteria may include patients who have marginal need or expected benefit; there are known side effects and long-term safety is unknown; the promoters are compromised by conflicts of interest. These are all relevant considerations. But the overall tone in the letter, and even more so the comments, is both judgmental and dismissive. (From commenters: “People are obese simply because of their own behavioral inability to control their diet . . . the solution still lies FIRST in the individual admitting his/her 100% responsibility in the problem weight.” “Obesity results solely from laziness and apathy, which consequently are the same traits that are leading to the devolution of our species.”)

The giveaway here is the headline: yes, overeating is of course a “behavioral problem”, not a surgical one, because in this context “behavioral problem” clearly refers to the etiology of a pathological condition (obesity), while “surgical [problem]” clearly refers to the preferred mode of treatment for that condition. The writer conflates the two categories, and then draws an inference from a logical contradiction of his own making: it’s true that the  etiology of this condition is not its treatment, but that’s true in every case, so that hardly tells against that treatment considered in and of itself. We can reinterpret the sentence to make sense, but only by making it obviously absurd: either “Overeating is a behavioral treatment, not a surgical treatment” or “Overeating, not surgery, is the cause of obesity”. There is a vacuity of clinical concepts here that suggests something else is at work in the writer’s animosity to certain kinds of treatments.

What the writer is really trying to say is this: “Obesity is caused by behavior, and should not be treated by surgery”. And the logical implication of that statement, and the letter and comments that follow, is this: “Obesity is caused by behavior, and therefore should not be treated by surgery”. The clinical counter-indications for surgery (and medical treatments for obesity – he’s against pills, too) that the writer details do not really seem to be the issue in his mind. Instead, certain treatments are ruled in or out categorically, on the basis of criteria of appropriateness that seem to hinge on his view of what health and medicine are fundamentally about, or how they are fundamentally related. There is a sense that diet is better than medical treatment because it is lower-risk, but also a sense that people who brought their conditions upon themselves behaviorally should be expected to work out their own salvation without clinical intervention. There is a clear implication that the writer would still object to bariatric surgery even if it were safer and more effective, simply because it’s not the kind of treatment he thinks this condition should get, in some essential sense (“obvious[ly] . . . the solution to a behavioral problem is not surgery”). Because the condition is behavioral, the treatment should be behavioral: QED.

From this perspective, the choice of treatments for a given condition depends on some sort of criteria of categorical appropriateness – a determination of what kinds of treatments are appropriate to any given condition, only after which do questions of safety and efficacy come into play. (This becomes more obvious in the letter above when the writer airily dismisses the notorious psychological difficulties of dieting with remarks about “responsibility for one’s actions”.) And this is the question that really got my attention about this issue. The concept of “appropriate” treatment is one that gets to the heart of healthcare as a practice, and of the ethical dimensions of such seemingly scientific concepts as the definition of disease, relative risk, and clinical indications for treatment.

To define clinical indications in some way other than in terms of clinical efficacy establishes medicine as a categorically defined practice: a praxis incorporating certain beliefs or techniques that are “just right”, and eschewing others as “just wrong”. The old ethic of “doctor knows best” exemplifies this idea to some extent (in regard of the roles of patient and physician: the doctor prescribes; the patient complies). More broadly, medical ethics based on a perception of distinctly medical virtues and traditions (Pellegrino’s “internal ethic of medicine”) makes all of medicine categorical; more than that, it moves the locus of medical ethics entirely inside the profession, such that what is right or wrong for a given patient is what is or is not in keeping with the behavioral standards applicable to the doctor. Even more modern theories of medical ethics do the same to the extent that they perceive specific types of treatments as right or wrong in and of themselves.

The movement toward patient autonomy and patient-centered care challenges this ethos at a basic level: the whole idea that patients may determine their own interests for themselves necessarily implies that healthcare is defined as serving those interests (or else we get a macabre dissociation between what patients need and what healthcare is for). The patient-centered ethic has fundamentally reformed healthcare practice in many areas, most notably refusal and termination of unwanted treatments, and more indirectly through the rise of cosmetic, nutritional, sports- or adventure-oriented, assisted reproductive, and other forms of “aspirational” (rather than pathology-driven) healthcare. The idea that what patients need is not determined by the pursuit and maintenance of “normal species functioning” – never exceeding its bounds and normal range, either positively or negatively – throws open a potentially unlimited range of possible treatments for any given condition, and indeed a potentially unlimited range of praxis under any conditions, whether or not defined in terms of disease and treatment. (The body modification movement blows the doors off the disease/treatment model, and increasingly off of any old-fashioned notions of normal species functioning.)

From this perspective, it is impossible even to formulate a declaration of the form: Because the condition is ________, the treatment should be ________. Radically patient-centered care does not require a “condition” to authorize a “treatment”, and takes it as fundamental that some patients may deny that an otherwise-recognized “condition” even exists (as in the case of the “fat acceptance” movement), while others may perceive, personally, a pathology in what would previously have been perceived categorically as normal (as with gender identity disorder). In addition, the particular best treatment for any given patient, whatever their circumstances, will be the one that best meets that patient’s interests as they themselves understand them – which may well be a riskier surgical procedure rather than a more burdensome lifestyle change, or vice versa, as they themselves perceive is best for them.

The significance of this non-categorical, patient-centered, situationally-responsive understanding of healthcare praxis is enormous. Aside from the overt impact on practical healthcare that the patient-autonomy movement continues to have, embracing a truly patient-centered ethic of care guides thinking about how to understand patient needs and how to meet them. In particular, it rules out categorical thinking of the type that prohibits providing certain treatments (with due consideration of cost, risk, and expected benefit) for a given patient or category of patient because they do not conform to some generic standard of appropriateness, and it requires that the patient’s own understanding of their goals, priorities, and risk-tolerance, be the determinative factors. Clearly the message hasn’t reached all corners yet.

4 Responses to ““Appropriate” Treatments: Categorical, or Situational?”

  1. Jason Monroe Says:

    KevinMD has always been one of my favorite medical bloggers. I do feel that most patients who attempt a low-calorie diet initially lose weight just fine.

    This therapy seems to work as long as the patient is compliant. When the patient is no longer compliant with the therapy, it (of course) does not work. The problem is not with the therapy; the problem is that there is no support in the society that we have created for the patient to comply with it.
    Jason Monroe´s last blog post ..5 solutions to alarm fatigue in todays hospitals

  2. Kevin T. Keith Says:

    Thanks for commenting.

    Support systems and societal pressures – especially including the aggressive, deliberate promotion of grossly unhealthy eating strategies by the food industry – are a big part of the issue in the question of the efficacy of dieting. Human psychology and possibly evolutionary history have a lot to do with it as well. The result is that effective dieting is extremely difficult in affluent societies where large amounts of unhealthy foods are freely available and aggressively marketed.

    For those reasons, “compliance” is I think a red herring in this issue. There are so many different model diets (not all of them healthy), and so many approaches to dieting, that a person nominally on a “diet” may have almost any possible eating strategy, from starvation to binging. “Compliance” with dieting essentially means eating in a way that causes weight loss – but then the argument about compliance becomes circular. (You’re compliant with the diet if you’re losing weight, so of course those who are compliant are successful at losing weight and those who are not compliant are not – by definition. But that tells us nothing about what it takes to succeed on a diet.)

    The real question is “what practical steps does it take to lose weight?”; the answer cannot be “eat in such a way that you lose weight”. A more sophisticated, and more useful, answer is needed.

  3. DaisyDeadhead Says:

    First, I am breaking a personal rule by commenting here… I never comment on posts that use the word “praxis” (I have list of other words too), since they are usually waaay over my uneducated head. So, bear with me please.

    But it seems to me, surgical intervention is a way of *forcing* a behavioral change… so the treatment IS behavioral, sorta kinda. Isn’t it? It’s a physically-enforced low-calorie diet. (surgically enforced?) The reason it upsets this person is therefore Calvinist: you *have* to do it the old fashioned way and then you will learn the error of your ways and sin no more. (he gives the game away by putting down drugs too)

    I recently lost 40 lbs (yay me) and midway thru this experience, tried to write about it and the Fat Acceptance Cops were all over my blog, yelling at me. And it made me wonder if there is any way we can talk about fat in a fatophobic culture without offending SOMEONE. I tried for the more sophicated, useful answer that you speak of (like I think one key to our obesity epidemic is the fact that they only give us working-class schlubs a half-hour or less to eat lunch, so we shovel it in as fast as possible, messing up our satiety signals… just as night-shifts mess up our natural melatonin… ), but people were still offended. I realized its because it *always* comes down to behavior in *some* way (eating and dieting are both BEHAVIORS), and in a Calvinist culture (yes it is) this is seen as berating people, not as trying to find answers.

    Interested in bioethics, even when its way over my little head, so I’ve linked your blog. :) Thanks for listening.
    DaisyDeadhead´s last blog post ..Retro politicians

  4. Kevin T. Keith Says:

    Hi, Daisy:

    Sorry to take so long in respond, but thanks for commenting!

    I think you’re right about the Calvinist streak in this phony distinction between “treatment” and “behavior”. There is a real, and very strange, moral perspective taken on many behavioral issues by a certain kind of mind, and it’s extremely counterproductive in health-related contexts. That also rolls over into the hostile and unsupportive environments we are thrust into; if everything in your life is your own fault, there is no obligation to create an environment conducive to real flourishing.

    Obviously you’re right, too, that surgical treatment for obesity is largely a behavioral-reinforcement strategy. Why shouldn’t it be? the idea that you are only allowed to modify your own behavior through the most arduous mechanism possible is simply perverse.

    Congratulations on your own success, and I’m glad you aren’t letting anyone take it away from you.

    I’m glad to hear of your interests and I hope you’ll come back. I don’t believe your self-deprecating remarks, and I hope you don’t believe them! Thanks for contributing.
    Kevin T. Keith´s last blog post ..Scientifically Documented! KTK is More Right Than Almost Everyone!

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