Curing the Ill – Should We?

There will always be the sick among us and it is a basic premise of ethical and religious systems that it is our responsibility to care for them and, where possible, to cure them. Even ignoring morality and focusing on self-interest, most people would be willing to expend the resources necessary to care for others in exchange for the guarantee that they will, themselves, receive such care when they are sick. It's likely, however, that they would express their support of the concept of caring for the ill in moral and ideological terms rather than self-interest.

While there have been, from time to time, some who would leave their sick and disabled on the side of the mountain to die, this has been viewed, by and large, as an aberration, and most civilized societies make health care a high priority. We see provision for the needs of those less able than ourselves as an obligation which is not lightly disregarded. In this country there is a sophisticated mix of medical and social programs which are addressed at these needs. In the medical field they involve private insurance, Medicare and Medicaid, “Obamacare,” as well as some institutions supported by governmental funds to provide service for those not otherwise covered. While it would not be accurate to suggest that the level of care is equal for all of our citizens and non-citizen residents (including undocumented aliens), the means exist for provision of some service for everyone.

That condition, however, does not always obtain. Situations can arise in which providers are forced to "ration" care by one system or another in order to function in a satisfactory manner. The paradigm of this situation is the triaging which takes place at the time of a disaster or a military engagement, when the number of individuals requiring attention is greater than can be handled by the system. At such a time a sorting of patients is made according to preset guidelines to determine who is in greatest need of attention or who is most likely to benefit from it. Those who do not meet these criteria would only be seen when, and if, resources later become available.

And there isn't unanimous opinion that tax money is the appropriate source for the costs of medical care – especially terminal care. Notwithstanding the moral strictures, they feel that people should pay for their own medical care, either directly or by the use of private insurance. Some acknowledge the inability of the poor to afford such care, yet many would deny them public funds to get it. They view such as charity, and maintain that charity is the responsibility of the individual, not the government.

It has, however, become a “given” that health care is a right. It's not explicitly in the Constitution, but our nation – indeed, many nations – consider it a state responsibility to ensure the health of all those living within their boundaries, whether or not they are citizens. It is decreed by medical ethicists and accepted by those on both the left and right (though with different degrees of enthusiasm) that some form of guaranteed care be available to all. The Republican Party assures us all that they'll repeal Obamacare and replace it with a “better” version of health insurance. Even they agree that some plan is necessary. (I don't know if, by the time this is published, changes will have been made.)

But is it? Would the knowledge that each of us is responsible for his own health care, and the government won't pick up the tab for those on welfare, help to encourage some of those who aren't doing so already to seek employment? Similarly they reject care for those here illegally. And those who are interested in the most efficacious use of health care dollars and other resources may consider it reasonable to deny care to those either deemed “unfit” or unsalvageable.” Another group that might approve are those who (secretly) might want to “pull the plug” on suffering family members, but would feel guilty if forced to make the decision themselves. I personally don't subscribe to all of those ideas, but we're burying our heads if we don't recognize that they exist.

I won't be subtle or deceptive. I want to be sure that, when the time comes, I receive the best available care. I've been paying for it and I want it. Ideally it should come from my own funds and insurance, or be provided by charity. However I don't trust my fellow man to care about anyone but himself, so, if the “crunch” should ever come, I'd rather rely on the government. Not that I trust the government and politicians. I don't. But I know that the prime goal of politicians is to be elected, so they'll do everything they can to guarantee the safety and health of their constituents. They care about themselves, so they care about me and every other voter. They're sure to vote for health care – especially since the voters will wind up paying for it.

It's not a matter of curing the ill. But they want to be elected and I want to be cured. Whether my life is worth anything to others – whether the use of medical resources on me would be justified in their eyes – I agree that it is society's obligation to care for the ill. Especially me.

March 5, 2017

Great Expectations

I have no beef. At least no legitimate beef.

When I was born in 1939, a white male (it's not a politically correct designation but I am what I am) had a life expectancy of a little less than 64 years. I'm almost 77 so I passed that a while back. Even today, in 2016, the life expectancy of a boy born now would be 76.3 – down a little from last year – so I'm ahead there too.

The progress we're making in treating disease successfully, and in increasing life span, is truly amazing. Much as we may insult the medical profession and blame doctors for the ills of society, we've all benefited. Some want more and want it faster but they, too, will live longer (and have more time to complain) than would have been the case in the past. The biblical mandate, to provide for his complete cure (Exodus 21:19, translation by Rabbi Aryeh Kaplan), has been taken very seriously. (Hu)Man(ity), was made in the image of G-d, and, while many are working toward our moral improvement, medical scientists are learning more about our bodies, and how to improve the world around us, in quest of more complete cures.

There have been major improvements in the available diagnostic tools, making it easier to discover diseases earlier and to characterize them more fully and accurately. And, or course, there have been, over the years, vast improvements in all forms of therapy – medicinal, surgical, rehabilitative, and even alternative means.

The research continues. Every day there is new information learned not only about specific diseases, but also about aging in general. Perhaps some day we'll be able to increase life spans based on this kind of information, rather then piecemeal through the treatment of particular maladies. But that's for then – not now.

I'm the beneficiary of some of these medical advances. MRI, CT, and a variety of blood tests, including genetic screens, have contributed to the ability of my doctors to understand my illness. Modern surgical techniques and recent medical therapies have also been employed in my treatment. Will they help? Only G-d knows, but what is possible for mortals to do is being done. I'm lucky – but I think I've said that before.

Noting my good fortune, however, doesn't solve all of my problems. I'm slower, more tired, and less steady than I used to be. And while my gustatorial preferences haven't changed, I find that I fill up much faster than was the case before.

Several years ago I volunteered for a study at the Albert Einstein College of Medicine. The stated intent was to investigate both cognitive and physical abilities in people as they aged. From the perspective of cognitive skills, I recognize diminishment only in the ability to remember some words. The ideas are clear but sometimes I can't recall the word that goes with it. (It's interesting that the mind can visualize concepts without requiring the words that go with them. Cognitive content and the words that identify and describe it seem to be separate functions, and we don't require words to have ideas. It's hard not to wonder, though, the extent to which it was necessary to have vocabulary in order to formulate and imprint the ideas in the first place.) That, apparently, is a common problem associated with aging, and my wife and I have dealt with it by helping each other with words.

In any event, the study has focused my attention on aging as one of the contributors to my current physical difficulties, but I cannot ignore the disease itself and the psychological baggage that accompanies it. And, to a degree, I can't dismiss the thought that the placing of chairs, beds, tables, and other devices to make life easy for me isn't in fact making things harder by being in the way. Oh well, I'll probably never work it out.

But I've already outlived most of my cohort. That's what the numbers tell me. So I guess that I win. And I'm not tossing in the towel just yet. I still have goals. Mostly they're sort of deadlines. They're primarily family events that I want to attend, and I'm hopeful that I'll be fortunate enough to do so. My (and my wife's) sixtieth anniversary is June 26, 2020. I'd like to be able to celebrate it, although I won't hold my breath (or maybe I will). Bargaining won't help. The Judge of all the earth will do justly

There's another kind of goal, though, that I've long pursued. We – human souls – are children of G-d and made in His image. We are called upon to love and care for each other as He loves and cares for us. Helping each other and having responsibility for them – that seems to be one of the absolutes that cultural relativists say don't exist. But they do.

If I can have helped or guided one other, my life will have been worthwhile – at least to me.

December 31, 2016

Cures?

My creatinine (a marker of kidney function and hydration) is slightly elevated. So I was advised to drink more.

Fine. Reasonable.

I told my oncologist's nurse – the one who told me to drink more – that I'd have more tea during the day. “No” she said. Tea has caffeine and would cause a diuresis. I'd lose more water than I'd take in. I didn't say much. That's not what I learned in medical school, but that was more than a half-century ago and medical opinion might have changed.

But it hasn't.

According to Bruce Richardson, a columnist for Tea Time magazine,

Tea consumption does not produce a negative diuretic effect unless the amount of tea consumed at one sitting contains more than 300mg of caffeine.

At an average 50mg of caffeine per cup, this is equivalent to six cups of tea at one sitting.

And

Dr. Jeffrey Blumenthal, Director of Antioxidant Research at Tufts University in Boston. Speaking at the 2012 International Tea & Health Symposium at the Department of Agriculture in Washington, DC, Dr. Blumenthal had this to say about the subject:

"We now have more than sufficient data to get over the myth that somehow tea is a diuretic and dehydrating. It is not."

Too much of what we accept is myth and old wives' tales.

Perhaps, as “everyone knows,” chicken soup is the universal panacea. Indeed, I saw in an eighteenth century medical book I once owned, that chicken soup, used as an enema, was a useful therapy for something. I can't remember what it was intended for, but I can't imagine it had any particular value. Sounds like a waste of good chicken soup. (Even bad chicken soup would probably be of no value as an enema, though I can think of no better use for it.) I'm reasonably certain that many of the things we do today will, in future years, be viewed as myths and superstitions, yet today we put all our trust in them.

The same nurse advised me to wear shoes when I walk because a neuropathy of the feet was one of the side effects of a drug I was taking and I had started to become unsteady. I'm reasonably certain that this is a standard teaching of nurses (and mothers) but I choose to ignore it. Shoes make my feet hurt and make me more unsteady, and I walk (indoors at least) better in soft slippers. She never asked me anything about other foot problems; she only advised that I wear shoes all the time. One size (of therapy) fits all.

You've heard such advice before. It may have come from the media (usually regarding food, cancer, heart disease, and diabetes) which are quick to publicize first (and unverified) studies; it may have come from others who pass on “wellness” advice and what they've heard or what everyone knows – even the doctors who, everyone knows, are hiding it from you; its origin may be your grandmother – the font of all the wisdom of the ages. And there are the views of those who would help us cure disease by using “alternative medicine” – a fashion that has provided additional options, often of no value – to those easily swayed by both the latest and by the time-honored explanations of measures likely to provide good health.

Some of the therapies, irrespective of the source, are associated with success, but the same can be achieved by a variety of placebos. Others simply occupy the patient until “nature takes its course” and he recovers – time heals some wounds. We should not ignore the fact that some have a suggestion of scientific validity and should be investigated further. However we should await the results of those investigations before proclaiming their value.

But most of these therapies are based on belief, and won't yield to logic and any information contrary to what their proponents “know.” Thus the nurse (believes and) advises that tea will cause dehydration, even though there is ample evidence that this is not true. Too many people are swayed by outdated ideas which they won't surrender no matter what the contrary evidence. All the claims of those who practice allopathic medicine are viewed skeptically if they disagree with common knowledge or the views of “experts” promoting “feel good,” or “feel superior” methods for dealing with our ills – or what we think to be our ills.

There's no cure for this disease. I won't try to defend the medical profession because I'll be accused of being part of the conspiracy to malign therapies other those of the “club.” Even when ancient and alternative methods and medicines delay proper treatment, they're seen as valid alternatives to standard ways.

Sometimes, as the saying goes, the cure is worse than the disease.

Ending LGBTQ? Bending Gender

According to (Dr. Ann) Moir and (David) Jessel, (“Brain Sex”), there are different phases in the formation of sex and gender identification. DNA controls underlying gonadal anatomy but (primarily male initially) hormone flows govern “brain sex” (the unchanging male or female “wiring” of the brain), attitudes, puberty, and gender identification, though these flows occur at different times and the hormones come from different sources (fetal gonads, adrenals, mother, exogenous).

Some of the mechanisms are known and are controllable or reversible. Some – especially exogenous hormones during pregnancy – have already been identified and addressed. It's also clear that the involved factors and changes begin at conception but many take place later, through pregnancy, childhood, and into the adult years. Some occur before pregnancy is even confirmed. Under ideal circumstances (at least “ideal” according to the view of most people) the various mechanisms and stages would be identified when they are occurring, offering the possibility of correction, but that's not always the case yet.

Exogenous hormones can be used to affect attitudes and gender identification, and can be used to lessen the frequency of homosexuality, trans-sexualism, and similar conditions. One thing seems clear: that nurture – whether societal values, parental pressures, the acts and temptations of others – play little if any part in the process apart from legitimizing it.  (Consequently behavioral modification is unlikely to be successful.)  Members of the LGBTQ community don't get there because they have been forced to by others, but because factors in their development made them what they are.

From the medical standpoint we can sometimes regulate what will happen. But ability is not license. Ability raises a different question: should such regulation be undertaken or does it suggest a sexist view that deviation from “normal” identification (and practice) is abnormal? And that question raises many others. For example, what are “disease” and “deviation?” And where does “normal” end and “abnormal” begin? When does a desire to prevent the “abnormal” imply a devaluing of those who are already (and unchangeably) “abnormal?” Does such a policy – to correct Nature's “errors” – further stigmatize those who may already feel marginalized?

We might also wonder about whether “perversion” – which now results in an individual being placed on a public list and being labeled for life as a sexual offender – is part of the spectrum. If it is, should we try to deal with it. Castration is practiced in some countries. It is a kind of hormonal therapy, though it is rightly viewed by many as too extreme. Exogenous hormones, which are sometimes used on these individuals, are a reversible alternative.

But the implications are never-ending, both in terms of philosophy and practice. We live in a world where determination of fetal sex is possible and abortion legal. In some countries, especially China, the practice of abortion so as to have a child of the desired sex is common. Is this moral? Is it sexism? If someday, by manipulating fetal genes, we become able to change race and the parents seek to have it done, would it be racism to do so? Is society's emphasis on youth a manifestation of sexism? And by treating and rehabilitating the disabled (or differently abled as is the current politically correct jargon) are we expressing a disdain for those who are afflicted?

Perhaps we should first consider the health professions in general. Are we permitted to treat the sick. By doing so we are not only opposing the “natural” – the actions Nature has taken – but also labeling members of our population as “deviants” from health. We are separating them from the rest of us.

And the issue is even more troublesome. Every procedure has risks. What chances are we willing to take? That is especially relevant when we consider fetal procedures. To what degree may we put our children at risk? (Actually the legalization of abortion has answered this question.)

The original issue can be viewed as a model to consider when confronting all of these questions. At least I view it as such. From my perspective our obligation is to future generations, not to our own. If there are some who feel threatened by therapies that suggest that they are other than we would wish them to be, so be it. They certainly recognize the prejudice that exists in society and, presumably, wouldn't want to impose it on others if it is preventible. Criteria will have to be found, however, to identify what represents “disease” justifying therapy. I recognize two.

The first criterion – and it is the one that has governed medicine for millennia – is “sickness,” which I understand to be any condition that shortens life or makes it difficult, for the individual suffering from it, to enjoy life. To a great degree it is internal. While there may be determinable criteria that can be recognized by others, that is not always he case. Pain and psychological suffering are only obvious to the victim.

The second criterion is external. For better or worse we all have opinions about right and wrong, about normal and abnormal, about desirable and undesirable. And we have to live with others whose opinions differ from our own. We live in a prejudiced world and that is not likely to change soon. We have to accept it. And for that reason I think that therapy to minimize the number of people who differ sexually from the average is warranted. The time will come when it is possible to identify and treat those otherwise destined to be members of the LGBTQ group, and I suspect they'll be more comfortable in “normative” roles than they would be otherwise. That view is not meant as a denigration of anyone who differs from the societal model, but as a recognition of reality.

Of course such therapy (and that to deal with other “isms”) should only be available as an option. Different societies have different “normative” patterns. That is certainly true of race. Even if someday it is possible to alter race genetically, such “normative” patterns in Norway, Nepal, and Nigeria will be different. And variety will remain an important feature. Many of those who differ from the majority will wish to remain as they are. Many will desire to retain their identities and their heritages, even recognizing the biases they'll face.

But that should be a choice, not a sentence. At least in terms of differing from the “norm” or suffering from a disease, that should be an available option. For them or for those bearing them. And we should give the matter thought now. Science has gotten ahead of philosophy and law and presented us with faits accomplis. It would be better to decide what we're willing to accept before we have no choice.

Happy Valentine's Day.