Moral Heuristics in Medicine: Judge Not Lest Ye Be Judged

We often evaluate people's health choices and the resulting outcomes through a moral lens, even though many people think it is politically incorrect to do so, to "pass judgment" on others, a proscription that is especially strong within the medical profession.

But it is natural to do so.  The invocation "Thy body is thy temple" rings true from both a moral and a medical perspective.  If only people would treat their body as their temple, how the woes of humanity would melt away, and we would not have a looming physician shortage but rather a surplus!

I am not here concerned with whether or not it is appropriate to pass a moral judgment upon people for behavioral choices that affect their health.  It could be argued either way, i.e., that morality is nonabsolute and individual and that healthcare professionals have no right to make judgments based upon their conception of what is moral, or that there are certain "sins" such as sloth and gluttony that should be universally frowned upon because they are inherently bad for individual and public health.  Rather I am concerned with whether we selectively apply moral condemnation but disguise it under the veil of medical judgment, and how other choices that have health impacts are not imbued with a moral essence, also selectively.

When the alcoholic with cirrhosis is admitted with terminal liver failure, there is a collective sigh with the subtext "he did this to himself."  We condemn alcohol as a personal moral failing, and there is the everpresent lurking tendency to say, with moralistic overtones, "you reap what you sow."

I was reminded of this the other day when I admitted a woman with gastrointestinal hemorrhage who, surprisingly, was found to have esophageal varices.  Most likely, she is not an alcoholic but instead has NASH non-alcoholic steatohepatitis related to obesity, an increasingly common cause of end stage liver disease in obese people (including children).  But there is no collective sigh of exasperation with her moral failings, her gluttony of food rather than alcohol.  She's the poor woman with NASH, rather than the wretch with self-induced disease.

Pulmonologists can hardly talk about tobacco and its ills without overtones of moral condemnation.  So it would appear that while moral judgments can be made under the pretext of medical considerations, the opposite can also happen: the health impacts of a certain substance or behavior can be so dire as that the crusade against the substance or behavior can take on moral dimensions.

I'm not sure any of this is wrong.  Morality is a universal part of humanity and provides a set of intuitional guides for our daily behavior.  But I think we should be consistent.  We should separate morality from medicine or join them and consider the moral dimensions of behaviors that we don't currently have strong moral intuitions about.  Ask yourself which is worse among the following health behaviors and more importantly ask yourself why you make that judgment.  Do you have medical evidence that suggests that one behavior has worse overall holistic health impacts than another?

Are the health consequences worse from:

a.)  daily smoking of marijuana
b.)  drinking 4-5 drinks per night
c.)  being 50-100 pounds overweight
d.)  watching 3-4 hours of TV per day
e.)  not exercising (at all)
f.)  smoking 1-2 cigarettes while at the bar on weekends
g.)  working 80 hours per week
h.)  being socially isolated 
i.)  moving your family for your career every 3-4 years
j.)  using smokeless tobacco
k.)  taking prescription opioid medications chronically for pain
l.)  living in Baltimore, Maryland as compared to Salt Lake City, UT
m.)  remaining single throughout one's adult life
n.)  not reading and staying otherwise mentally active
o.)  riding a motorcycle or driving a car
p.)  owning a firearm or owning a swimming pool

My intuition is that, when we evaluate these behaviors, we utilize a heuristic based on moral intuitions about the "badness" or degree of "sin" of each of these behaviors, and that that heuristic is likely to be highly fallible.  The moral overtones of a behavior are poor surrogates for its real health effects, and moreover we can extend moral judgment to many behaviors that affect health but which we frequently overlook as important determinants of it.

Because of a comment from a former colleague on Facebook, I have modified and updated the list and will make an additional comment.  When I was attending the Johns Hopkins Bloomberg School of Public Health from 2002-2003, I would sometimes get weird looks as I showed up to class in motorcycle riding gear.  There were several group projects about mandatory helmet laws (Maryland already had one), and riding a motorcycle was considered in many ways an affront to the public health.  So was firearms ownership.  During one lecture, attended by two hundred or so students, I challenged a professor of public health who was maligning firearms ownership or motorcycle riding, I forget which, to justify why he "exposed" himself and  his family to the astronomical violent crime rate in Baltimore, Maryland, for the satisfaction of working at Johns Hopkins.  He was as speechless in that moment as I was unpopular in the School of Public Health.

This anecdote is emblematic of what I'm trying to point out in the post - that some behaviors have moral weight, and other similarly "bad for you" behaviors do not.  There is moral weight to riding a motorcycle or owning a firearm, there is no moral weight in the choice to live in Baltimore or install a swimming pool.  But, compared to living in SLC, UT, living in Baltimore statistically increases your risk of being murdered by 30 per 100,000.  That number is very close to the increase in the risk of death between riding a motorcycle and driving a car (increase of about 45/100,000).  But riding motorcycles has taken on a moral (or judgmental, if you will) character.  The choice of where you live has not.  Think very, very carefully about that.

Helping Those Who Won't Help Themselves: The Role of Personal Responsibility in Medicine

Give a man a fish, or teach him to fish.

It is a well known secret in medicine:  many of those we care for are unconcerned with their own care, as evidenced by their revealed preferences.  "What medications are you on?" the physician asks.  "I don't know, doc," comes the reply.  "Why are you on carvedilol?"  "I don't know."  "What was your last HgbA1C?"  "What's that?"  We have encouraged physicians and other professionals in the healthcare system to take responsibility for every aspect of patient's care to the peril of patients' own interest and investment in their care.  How often do you enter a room and find a patient researching their illness and its treatment, rather than surfing the internet or watching TV?  Is your patient more concerned with the timing of the next dose of antibiotic or the next dose of dilaudid?  How often do your patients keep detailed records of their past medical history?  Why does the intern or resident or PA or NP schedule follow-up appointments for patients, rather than the patients do it themselves prior to discharge?  Why must so many patients be coaxed out of bed and working with physical therapy?  The actions of patients reveal their preferences.  Those who are invested in their own care take responsibility for it and are knowledgeable.  Those who would rather watch television than work with physical therapy reveal other priorities and preferences.

All the hubbub about healthcare and health disparities has entirely glossed over the role of personal responsibility and accountability in medicine.  Some may find it inexcusable that many patients have so little investment in their own health care, expecting instead that the government, their insurance company, and the healthcare system at large allows them to abdicate their own personal responsibility without consequences.
(I am not here referring to people who are unable to care for themselves, but rather those who are perfectly capable but who shirk the responsibilities.  If you cannot accept this and wish to accuse the author of "blaming the victim" read no further.  Yes, the victim of disease is being blamed for any lack of personal responsibility that is contributing to poor health.)

If there is a lack of personal responsibility in medicine, there are several important implications that we should be concerned about.

Doctorin' with Double Effect: The Ethics of Withdrawal of Life Support and Oxygen in Dying Patients

There has been a lot of discussion about the ethical nuances of withdrawal of life support and provision of medications that relieve suffering but accelerate death, but precious little about an important aspect of end of life care that comes up all the time - what are our obligations regarding provision of oxygen to dying patients?

The withdrawal of life support is an activity (a commission) that is ethically protected because patients' autonomy and right to refuse treatments overrides the harm (death) that comes about when physicians act to withdraw life support.  This in itself is interesting because most states prohibit euthanasia (or the provision of prescriptions that enable patients to take their own lives), which is in essence a commission (as opposed to an omission) that accelerates death.  I'm struggling to understand the distinction, except that the withdrawal of life support restores the patient to a "natural state" and allows nature to take its course, whereas the provision of a prescription to allow a patient to overdose is a commission that seems to interfere with nature.  (Jonathan Baron has written extensively about our preference for "natural states" which often leads to worse outcomes.)  That takes care of the natural versus human distinction (which of course ignores that humans are part of nature), but I still struggle to understand why the patient in Oregon has to administer his own overdose, unassisted by a healthcare professional - what's the difference between a healthcare professional assisting with the administration of an overdose and accelerating death, and his removing life support and thus accelerating death, if both acts are in deference to patient autonomy, and both are commissions, and indeed both are direct actions, as opposed to indirect ones?  Maybe it's because you can act directly and cause harm in respect of autonomy as long as you restore a natural state (withdrawal of life support), but you cannot act directly to cause harm in respect of autonomy by causing an unnatural state (medication overdose).  I think this stream of consciousness has led me to the distinction.  Maybe.  The devil is in the details.