Self-centered Syllogism: Bad in public health, bad anywhere

I recently met someone who had seen a couple of my blog posts, was interested in public health, and asked a few interesting questions. My answers – or, really, comments – were things I have said and written about before, but his questions forced me to put them together, and in my opinion, the issues bear repeating.

The first question he asked was “why do we put so much emphasis on smoking but not on alcohol? After all, smoking never caused someone to beat their children or spouse, or to drive impaired and have an accident, or get into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the real answer is the incredible mortality caused by smoking. The CDC page identifies tobacco as the cause of nearly a half-million deaths in the US annually. While the data is from 15-20 years ago, and (hopefully) the mortality rate from tobacco has decreased as its usage has decreased, this is an astonishing statistic. Deaths from tobacco exceeded the total of deaths from alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco is the leading cause of preventable mortality in the United States”. It was, therefore, the focus of public health efforts because of its tremendous impact on mortality.

However, of course, alcohol is also a major problem, causing both death and severe morbidity (bad outcomes besides death). It is, as my questioner noted, highly associated with violence against both family members and strangers, with automobile deaths, with homicide and not-homicide violence. It also, of course, kills people who use it, from diseases such as cirrhosis and heart disease as well as many cancers that are more common in heavy drinkers. We all have heard someone who did something very bad (commit violence against family members or strangers, have a car wreck, etc.) say “It was the alcohol. I wouldn’t have done it if I were sober”. But they were not sober, they had been drinking, and probably had often been.

The American Addiction Centers alcohol.org estimate that 88,000 people die from alcohol-related violence and abuse and accidents. The site also notes that “The American Society of Addiction Medicine notes that between 28% and 43% of violent injuries, and 47% of homicides, alcohol has been estimated to be involved.” That is a lot, and it could be an underestimate, but it is the closest I can get to quantifying the attributable risk for violence from alcohol. The concept of “attributable risk” in public health can be understood as the percentage of “bad outcome X” that would go away if “risky behavior Y” went away. This is different from the amount that it increases an individual’s risk; some behavior “Y” may increase your risk a lot but, because it is relatively uncommon, account for less attributable risk. Examples include asbestos and lung cancer (very high increase in risk but a lower percent of cases, compared to smoking). Or, looking at it inversely in terms of what disease a risk factor causes, smoking and lung cancer vs. heart disease. Smoking increases the risk of lung cancer more than it does heart disease, but because heart disease is so much more common, the attributable risk from smoking, the number of lives that would not be lost if people didn’t smoke, would be more from heart disease than lung cancer. An example of “smaller percentages of larger numbers can be greater than larger percentages of smaller numbers”.

So what did I say about alcohol? He identified the fact that there is a very large industry of alcohol manufacturers and sellers, which have great influence. I noted that there was (is) also a great industry of tobacco manufacturers and sellers. He said that in addition to the manufacturers, there were also many businesses, restaurants and bars whose existence depended on the sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t drink too much”, a common “PSA” from alcohol manufacturers. The implicit message, however, is “do drink!”.

I think most of the members of our society, including many of those still smoking, recognize that any amount of smoking is bad for you, and more is worse, but I do not think that the same is true for alcohol use. The general attitude, even among medical and public health professionals, seems to be “a lot of drinking is obviously bad, for you and for others, but a little – like I do – is not.” What could be wrong with a couple of beers? A couple of glasses of wine? Especially if you’re not driving? Aren’t there studies that show a little red wine is good for you?

There are such studies but they are dated, poorly done, and wrong. Pretty much, while more is worse, there is no amount of alcohol consumption that is good for your health, and any amount is somewhat bad. We disparage those who use other drugs (heroin, cocaine, crack, meth, even still cannabis) for entertainment, but much of our society is actually built around alcohol as the “social lubricant”. Restaurants, bars, parties. Family events like weddings and funerals. Most of such entertainment revolves around alcohol. Perhaps the only place where alcohol is not the key component of “having fun” would be at an AA meeting! This issue is seriously joined by Holly Whitaker in her book “Quit Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”.

The key here is that so many people drink (if “responsibly”, by which they usually mean “not too much” and “not when driving”) that they have to justify themselves by saying it is OK. I call this the “Dirk Gently Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”. The lead character, who dies on the first page, was a millionaire who made his money by essentially developing syllogisms that took you from the data you had to the conclusion you had foreordained (his biggest client was the US Department of Defense). This is pretty much what we do in lots of areas, including alcohol use; we decide on what we want the answer to be and then look for evidence that supports it.

My new friend noted his son had been in a public health program a few years ago when the big emphasis was on obesity and its health effects. I nodded, but it not so much any more. Obesity has big health effects, yes, but it is also easy to disparage people who are overweight. This is a manifestation of another common tendency among people (including among health professionals): to be critical of people who do (or don’t do) things that come easily to you to do or not do, and conversely minimize the significance of the negative behaviors that you do (or don’t do). If you are naturally thin and have an no difficulty keeping weight off, it is easy to criticize those who are overweight. However, if you like your fancy wine or craft beer or expensive single-malt scotch, you don’t think drinking is such a bad thing. Or, for that matter, being self-righteous.

Public health is good and important. In the US, it is grossly underfunded compared to individual medical care (about 1% of health care dollars). But, like much of medicine it is also subspecialized. To a large degree, public health researchers go where the money is available for grants – in obesity, or smoking, or violence prevention, etc., and become specialists in that area. It is (or should be) different in primary care. As a family doctor, I can measure and counsel you on your blood pressure, but I cannot ignore your diabetes or lung disease and just refer you to another specialist. Similarly, while public health specialists “do obesity” or “do child seats”, this is not an option for the family physician. I need to help you to stop smoking, but cannot ignore that you need to use a seatbelt. Or get vaccinated. Or would have a greater probability of better health outcomes if you lost some weight. Or did not drink so much. Or at all.

Judging others for doing (or not doing) what we find it easy to not do (or do) and minimizing the damage caused by what we ourselves do is a big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive, appropriate, or helpful or good for anyone, and are especially dangerous coming from medical or public health professionals.

Should hospitals and doctors make value judgements about who deserves treatment?

I heard on NPR’s “Here and Now” (Sept 9, 2021) that Jimmy Kimmel, the late night TV host, had expressed anger and frustration with people continuing to refuse vaccination for COVID-19. He noted that many hospitals no longer have available Intensive Care (ICU) beds available, and were going to have to triage who was admitted to them. According to the host, Robin Young, Kimmel said the decision was easy: you have a heart attack, you’re in; you have COVID and didn’t get vaccinated, you’re out. (His monologue is summarized by The Hill, among other sources.) Kimmel is not the only one to express outrage at the unvaccinated -- “shock jock” Howard Stern has responded to those who would cite their freedom to not be vaccinated with “F—k their freedom; I want my freedom to live!”— and is also not the only one called for such “ICU triage”.

Daniel Wikler, a professor of medical ethics from the Harvard School of Public Health was Ms. Young’s guest, and he said that, while he understood the anger that Kimmel and others were expressing, and empathized with it, he did not believe that it was the business of doctors or hospitals to make such decisions. It was the tradition and history of medicine, he said, to treat the illness of the patient if it was treatable, not to decide that someone had done something to themselves to make them undeserving of treatment. As an example, he noted a skier who might ignore all warnings, ski down the back of the hill, and get injured. There are lots of other potential examples, and they are valid.

I agree with Dr. Wikler on both points. First, I understand and empathize with Mr. Kimmel and others who are furious that those who have refused vaccination not only threaten the health of the rest of us but also end up utilizing a huge amount of health resources and services that not only can limit access to these services for others in need, and in any case cost huge amounts in time and effort by health professionals as well as in money. But I also agree that doctors and hospitals have no business refusing to care for these people, and that a core ethical value in medical care has been to provide care, if you are able, to help the illness of the patient, not to judge whether they are worthy of care because of their previous actions. One of the most dramatic and important examples are medical facilities in war zones, which are obligated by the Geneva Convention to treat all injured on the basis of need, not which side they fought on. To treat one’s own soldiers and not injured enemy soldiers who are prisoners is a war crime.

Many of those people who have the heart attacks that Mr. Kimmel thinks should get them into the ICU smoked cigarettes, or ate a very poor diet, or did not exercise, or all of these. While I’m sure that there are some people who are judgmental and smug enough to believe that they should suffer the results of their own life decisions and not receive care, this is not the approach that doctors and hospitals take.

There are certainly many people whose illnesses are at least partly a result of other poor decisions, including use of alcohol – both heavy lifetime use and even one episode which led to the car accident that has them in the emergency room – or other drugs. In addition, while less common than from alcohol, illness and death related to illegal drugs such as opiates and opioids and stimulants is still very common; we have all heard of the “opioid epidemic”. And there are infinite possibilities for blame when you go beyond “sins of commission” – things you did that were bad for you – and enter the realm of “sins of omission” – thing that you didn’t do that are, at least in the view of the one making the judgement, would have been good for you (e.g., diet and exercise).

Back to domestic hospital use, I would like to discuss two examples from my own experience. Suicide attempts are definitely self-inflicted, but the motivation to act is often transient, and many people who attempt suicide and survive do not attempt it again. Guns are very lethal, however, with well over 90% of suicide attempts by gun being “successful”; drugs are less so. My son killed himself with a gun, but if his attempt had been with a less lethal method, I  certainly would have wanted him treated.

On our inpatient services, residents and I have cared for many people who are repeatedly admitted with the effects of their use of alcohol or other drugs. One person I remember well. Regularly admitted for the toxic effects of alcohol overdose, on treatment and release he always pledged to get treatment for his disease, most strongly motivated by caring for his daughter, but never followed through. After many admissions, some residents thought it wasteful to continue to treat him and argued against it. My position was not only was recovery a difficult process, often with many failed attempts, but that our role was to treat his medical condition and refer him for treatment for his alcoholism. We could make the judgement that he was at fault, and each of us might have our own opinion about whether he “deserved” treatment, but that was irrelevant to our obligation to take care of it. It would be a slippery slope indeed. And I would be remiss to not point out the most common reason people are “triaged” to not receive care, at least in the US, is financial: they do not have money or good insurance. That is totally immoral and unacceptable.

There are some differences with those who refused to be vaccinated against COVID or wear masks or distance, but these are variations on a theme. Yes, they put others as well as themselves and their families at risk, but so do those who drink and drive or use other drugs, or who do many other things. It is our job to take care of them to the best of our ability. To do otherwise is to risk great hypocrisy, thinking that those who do the dangerous things we ourselves do are less culpable than those who do dangerous things we do not do and decry. I call it the “Jesse Helms fallacy” after the former powerful North Carolina senator who both opposed treatment for people with HIV/AIDS, who he said were suffering God’s punishment for their homosexuality, and also smoked like a chimney and fought for the tobacco industry. When he had developed heart disease, he sought and received treatment, despite being largely personally responsible for it.

That so many are refusing vaccination and care that there are no beds in ICUs in many states (as a person from Alabama did from heart disease after being unable to get a bed in 43 hospitals in 3 states, and as is occurring across the poorly-vaccinated South) is shameful, discouraging, and incredibly dangerous. These people are misguided, stupid, and many are even evil. But we also hear of those who (because they are dying, to be sure) regret their decisions. We can feel some sense of self-righteousness when we hear about anti-vax personalities who have died. If we are in institutions where there are not enough beds and patients have to be triaged, that triage must be on the basis of their condition and our ability to help them. The social/political fight cannot be waged at the bedside of an individual patient.

As much as we might be tempted to do so.