Correspondence
The Tyranny of Health
N Engl J Med 1994; 331:1660-1661December 15, 1994
- Article
To the Editor:
Reading Dr. Fitzgerald's article, “The Tyranny of Health” (July 21 issue),1 reminded me of a comment a patient once made to me. After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.
1 ReferencesLewis E. Foxhall, M.D.
University of Texas M.D. Anderson Cancer Center, Houston, TX 770301
Fitzgerald FT . The tyranny of health. N Engl J Med 1994;331:196-198
Full Text | Web of Science | Medline
To the Editor:
The increasing criticism of unhealthy lifestyles is a direct result of spreading the responsibility for health care costs to the general public. Canada's tax-funded system of medical care brought about this change long before the current broad definition of health existed. When taxes are high, the cost of medical care is increasing, and rationing of services is introduced -- as is the case in Canada -- the public will inevitably criticize those who abuse their health and cost the system more.
T.B. MacLachlan, M.D.
408 Garrison Cres., Saskatoon, SK S7H 4B6, CanadaTo the Editor:
... Medicine in America is undergoing a revolution that will change the approach to health care from a hodgepodge of treatments to a true system focused on health as the measured outcome. Strategies for behavioral change will be the pillars of this new house of medicine. There is absolutely no reason, scientific or moral, to shrink from the use of these tools of culture in performing our art.
George W. Anstadt, M.D.
75 Panorama Trail, Rochester, NY 14625-1507To the Editor:
I strongly agree with Fitzgerald that we must spend more time helping patients cope with the reality of illness and the common tragedies of life. However, I am concerned by the message that physicians should downplay issues such as domestic violence, child abuse, and substance abuse because these are personal actions that a physician should not attempt to control. On the contrary, these topics are among the most important issues the primary care physician can touch on during a brief office visit. We may not be any more qualified than other people to address social ills, yet our unique position, which makes us privy to personal information rarely shared with anyone else, mandates that we not ignore these serious threats to health. By equating life with fate, Dr. Fitzgerald undermines the power of individual people to control their own health.
Albert DiPiero, M.D.
Harbor-UCLA Medical Center, Torrance, CA 90502To the Editor:
Dr. Fitzgerald overlooks the fact that people's lifestyles also have a substantial effect on society. For instance, smoking-related problems generate over $100 billion in health care expenditures annually. The average lifetime medical costs for a smoker exceed those for a nonsmoker by $6,000.1 Costs related to alcoholism exceed $120 billion per year.2 Problems associated with diabetes cost society an additional $105 billion each year. Each person with diabetes spends an average of five to six days in the hospital per year, whereas persons without diabetes spend an average of one day per year.3 Almost 30 percent of these costs are estimated to be the result of poor compliance with medical and dietary regimens; unhealthy lifestyles clearly have a cost.
Physicians must be empathic, but we need not absolve patients of any responsibility for their health. Patients need to be partners in their care.
Contrary to Dr. Fitzgerald's assertion, the tyranny of health is not in blaming people for their illnesses. The tyranny is that all members of society must pay for the health care of a few who choose unhealthy lifestyles, thus creating a need for health care where none would otherwise exist.
3 ReferencesJohn J. Whyte, M.D., M.P.H.
Duke University Medical Center, Durham, NC 27707Douglas P. Beall, M.D.
Johns Hopkins Medical Center, Baltimore, MD 212051
MacKenzie TD ,Bartecchi CE ,Schrier RW . The human costs of tobacco abuse. N Engl J Med 1994;330:975-980
Full Text | Web of Science | Medline2
Heien DM ,Pittman DJ . The external costs of alcohol abuse. J Stud Alcohol 1993;54:302-307
Web of Science | Medline3
Rubin RJ ,Altman WM ,Mendelson DN . Health care expenditures for people with diabetes mellitus, 1992. J Clin Endocrinol Metab 1994;78:809A-809F
CrossRef | Web of Science | Medline
To the Editor:
Fitzgerald points out that if we define health so that society pays for the care of the self-indulgent, we are in for a lot of mutual censure. When, she asks, should society start to regulate behavior? With intravenous drug use? With obesity?
We should probably distinguish more costly types of self-indulgence from others. Thus, smoking (which is responsible for 10 percent of health care costs1) and heavy drinking might be worth distinguishing from lesser indulgences. The social accounting might also show the other side of the ledger: having cars is worth risking road accidents.
To forestall social disgrace, virtuous folks might be offered a discounted, “if you play, you pay” health contract that stipulates reasonable self-care. However, we should consider the rights of those who just love excess and debauchery and permit them to elect more expensive, inclusive coverage for Sybarites. This would both permit me my pate, souffle, and mousse and spare me Fitzgeraldian tyranny. Otherwise, the cost of my treatment for hyperlipidemia might limit someone else's ability to be vaccinated.
1 ReferencesQuentin R. Regestein, M.D.
Brigham and Women's Hospital, Boston, MA 021151
Cady B . Payment by nonsmokers for smoking-related illness. JAMA 1986;256:1291-1291
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Fitzgerald replies:
To the Editor: I appreciate Dr. Foxhall's comment. I too learned from my patients: the woman with metastatic breast cancer whose family blamed her for not having had screening mammography; the obese woman whose every problem led to a single recommendation by her doctors -- weight loss -- which in turn resulted in the lack of effective therapy for her ongoing hypertension until she had a stroke;, the bleeding Jehovah's Witness who calmly pointed out to me, as I argued for transfusion, that her interest was more in her next life whereas mine was in this one.
I agree with Dr. MacLachlan about public criticism, indeed public ostracism. But physicians should not become party to it. It is our role to protect the abused and point out to the abusers that the scientific data that have provided them their weaponry of opprobrium are not always clear-cut or applicable to all persons.
Dr. Anstadt believes that medicine's mission is to change behavior using the tools of culture. I absolutely disagree. What is health that it can be so easily measured as to design an entire system around it? Whose culture shall we use as tools? What behavior will be acceptable? These are the questions that I was asking in my essay, and I believe the answers are not so clear.
I agree with Dr. DiPiero that domestic violence, child abuse, and substance abuse are important issues. But there is a certain arrogance on the part of physicians who believe that their position as physicians renders them authorities whose opinions carry weight in areas in which they have no special expertise. Certainly, part of our job lies in the discovery of persons harmed by such activities. However, we must not imply promises of cure or prevention that we cannot keep, since this would lead only to an erosion of trust in us. Until we know how to prevent or cure domestic violence, child abuse, crime, and substance abuse, perhaps we should refer these issues back to society as beyond our purview.
In response to Drs. Whyte and Beall, I did not overlook the fact that people's lifestyles have a substantial impact on society. Indeed they do. The question is how far we may go in constraining individual liberties for the well-being of society as a whole. Before doctors participate in major social engineering, they should consider carefully the following four questions: Who will be empowered to define unhealthy lifestyles? Doctors? Nutritionists? Exercise gurus? Who will decide when and if a patient is willfully noncompliant or noncompliant for reasons that may be beyond his or her power to change (cultural pressures, doctor's errors, poverty, ignorance)? Can we design a system in which patient autonomy and decision making are given a major role if noncompliance is punished by withdrawal of care? This is a heady paradox of modern times. Shall doctors serve as society's agents or as patients' advocates when the interests of the two are opposed, as they usually are, since all illness is a drain on the commonwealth?
In our criminal system, we acknowledge the legitimacy of defense attorneys, even though the accused appears manifestly guilty. Should not physicians, in caring for their individual patients, defend their right to receive care even if we suspect that “misbehavior” may have contributed to their illness?
Faith Fitzgerald, M.D.
University of California, Davis, Medical Center, Sacramento, CA 95817-2282
