Sickness.

The whole eugenics-to-eliminate-sickness thing has got me thinking about sickness, disease and health. I think it’s important to figure out what my mission is. Should I be stubbornly quixotic in the face of suffering?  It was definitely my view early on in my medical thinking, but I’m certain that it’s not right now.

More on this later.

Eugenics

I’m reading an interesting (if a little outdated) book by the eminent Australian scientist Sir Gustav Nossal called “Medical Science and Human Goals”.

He broaches the topic of eugenics in the chapter of the book entitled: “Medical Science and Human Evolution”. He expresses the opinion that so-called “positive eugenics”  (i.e. the selective breeding of desirable elements of the population) is clearly suspect ethically (who defines “desirable”) and at the very least unworkable. However he supports a “negative eugenics” (i.e. the prevention of elements of the population with clearly undesirable genetic traits from reproducing). He does not propose any sort of direct enforcement of reproductive limitations, but rather an encouragement of individuals who carry unpleasant genetic material to avoid breeding. This encouragement would be through education at a public-health level, and through genetic counselling.

I don’t think Nossal’s position is much less shaky than that of the positive eugenecist. Surely declaring traits which are compatible with life (say, type 1 diabetes), or even only somewhat compatible with life (say, cystic fibrosis) as “undesirable” is just as presumptuous as declaring some other trait (say, blonde hair or the ability to do maths) to be “desirable”. I have not yet encountered the ethics of genetic counselling, but I would be surprised if today’s genetic counsellor saw their role as anything more than to inform the patient of the risk of offspring having some condition, and informing the patient of their options. To take upon oneself the role of advocate for a course of action is to intrude on the autonomy of the patient, as (in most cases) the patient will be at a large expertise and even educational disadvantage in comparison to the counsellor.

There are more issues at stake here, however.

I have no doubt that people suffering with chronic diseases would generally not wish their condition on anyone else, nor would they see their disease as a good thing. A public policy of the eradication of a genetic condition through control of the gene pool would send a very difficult message to these people, however. Does someone with Huntington’s disease have a worthwhile life? Does a diabetic in some way fall short of humanity?

I think disease is a terrible thing. I do not, however, regard it as a personal enemy. In a world filled with chronic disease we are challenged to support the weak – at cost to society of time and money. I’m not saying that disease is a good thing, but I’m also encouraged by the opportunity it presents for us to show regard for other human beings.

I don’t think the elimination of chronic disease from our populations in this way (even if it were possible) would result in a net gain of utility for society. The mortality rate would still be 100%, our gene pool would be a bit more homogeneous, and we would have a society where a properly functioning body was a criterion for life, if only in the “should” sense.

Pretty much the movie GATTACA – which is an awesome film by the way.

Central Nutritional Control – economics and politics of diet

So we’re studying nutrition at the moment at med school, and I’m struck by the economics of diet (i.e. in telling a patient to eat a “healthy diet”, you are asking him not only to relinquish his favorite foods, but in most cases to bear a greater financial cost for the privelege).

 As a rank newcomer to the field of nutrition, I offer this wacky idea.

The National Economic Diet Board

Each year, the CSIRO audits the diets of a representative sample of Australians. Note is made of which foods are being consumed in surplus, and which are being neglected. Taxes and subsidies are then put in place to shape the economic incentives to more closely (how close would be a question of will and practicality) match the health imperatives.

The idea is to modify the behaviour of the population not through education, as is usually suggested, but rather through tinkering with market forces.

Such a plan is clearly impossible in a free market. Can you imagine the reaction of Domino’s Pizza to the imposition of a three dollar health surchage on each pizza?

What I really enjoy is imagining the political advertising that would run against this idea. The angle run by the Fat Industry lobby group would surely be that the government was taking upon itself a paternalistic role- that choice was being somehow circumvented. But how much choice does today’s five-year-old have when being indoctrinated with health messages at school?

Education in health issues at primary school is (at least in my experience) rarely considered to be ethically suspect, so why is governmental direction of individuals’ habits derided as characteristic of a “nanny-state”?

What sorts of interventions are appropriate for a government to make in the health and lifestyles of its people? What does “choice” mean in the context of economic and cultural pressure, not to mention ubiquitous advertising?

Safe Intake

Just curious: without looking it up – can you tell me what the current recommended safe alcohol intake is for an adult male and female?

Social History

Healthiest man alive?

We’re being taught to “take a history” at uni – which means interviewing patients with a view to diagnosis. There are four main parts: History of presenting complaint, Past medical history, Family history, and Social history.

In Social History, you try to gain some understanding of the patient’s life in general terms. Things like family situation, occupation, use of alcohol and tobacco, financial well-being, recent life changes, travel etc.

Lately I’ve been wondering - when is a social history healthy? It’s clear when a patient details a morose home life accompanied by a huge substance intake that something is wrong. But health is more than the absence of disease- so what is social health?

More broadly – who are the people living healthy lives? Who would you say is the healthiest person you know – health being in the social sense?

I’ve got some ideas…