I’m torn.

I can’t decide whether it was greed or stupidity that led the American Academy of Family Physicians to accept a corporate sponsorship from Coca Cola.

Greed is certainly behind the AAFP decision to create its “Consumer Alliance program.” I love the Orwellian title! AAFP is not allying with consumers. It is partnering with businesses. The businesses will provide money and the AAFP will provide legitimacy. Yet said AAFP President-elect Lori Heim, M.D. disingenuously claims:

The Consumer Alliance program is a way of working with interested companies to develop educational materials to help consumers make informed decisions so they can include the products they love in a balanced diet and healthy lifestyle.

No, it isn’t. The Consumer Alliance solicits money from corporate sponsors to enrich the AAFP coffers.

A partnership with Coca Cola defies comprehension. The American Academy of Family Physicians has been out front in calling attention to the link between soft drinks and obesity, particularly childhood obesity.

Soft drink consumption has increased dramatically in recent decades. The increase corresponds with the rise in obesity and diabetes in the United States. Some evidence suggests that sugar-sweetened beverages increase the risk of childhood obesity. No study has shown that these drinks increase the risk of diabetes, although this relationship is plausible not only because of the added sweeteners but also because the caramel coloring may increase insulin resistance.

The official position of the AAFP is to minimize Coke consumption; the official position of Coca Cola is to maximize Coke consumption. In fact, everything the Coca Cola Company does is designed to maximize Coke consumption and, therefore, profits. If they are giving money to the AAFP it is because they believe that the legitimacy they will gain in exchange will lead to increased profit. The conflict of interest could not possibly be more stark.

I suppose it shouldn’t matter how much you are asking for your soul when you auction it off, but I find it galling that the AAFP had sold its soul so cheaply. AAFP President-elect Heim says the payment “in the strong six figures.” In other words, it took less than a million dollars to convince the AAFP to ally with a purveyor of a product does not improve health and may actually impair it.

The AAFP has clearly learned nothing from the example of other medical organizations that have compromised their credibility with inappropriate corporate sponsorships. The American Medical Association suffered a major blow when forced to renounce a partnership with Sunbeam, a maker of home electronics. According to Quackwatch:

…[T]he American Medical Association announced that it would pay $9.9 million to the Sunbeam Corporation to settle a breach-of-contract suit… The suit was filed … after the AMA announced it would not honor an exclusive 5-year royalty agreement under which the AMA logo would have been placed on Sunbeam’s “Health at Home” products, which included heating pads and humidifiers. The endorsement plan, … had no requirement that the AMA test the products… An investigative report on the management decisions leading to the contract led the AMA’s chief executive officer and two other top AMA executives to resign.

The AMA has never fully recovered from the scandal and has seen its membership drop to less than one third of American physicians.

The American Academy of Family Physicians has made a terrible mistake. It has compromised its integrity and credibility by accepting money from Coca Cola. It should follow the example of the AMA and renounce the partnership. President-elect Heim has managed to besmirch the reputation of the organization even before taking office. Hopefully it is not too late for her to undo the damage.

I’ve been writing about the H1N1 flu for the past few days, and have been asked repeatedly if the Centers for Disease Control (CDC) has reacted precipitously by ordering the production of millions of doses of vaccine and strongly recommending that individuals at highest risk get vaccinated as soon as possible.

To understand why the CDC has taken the aforementioned actions, you need a little background in history, epidemiology and virology. No one including the CDC knows what is going to happen, but they are using experience as a guide. Let me share (in a simplified form) what is known, then you can decide what you would do if you were the CDC.

History shows that the influenza virus, while typically mild, can mutate to forms that are deadly. The great influenza outbreak of 1918 (the Spanish flu) killed tens of millions of people. Curiously, the hardest hit were those who were young and healthy. They would come down with the flu, develop lung complications, and quickly drown in the fluid that filled their lungs. So although such outbreaks are uncommon, recent history shows that a flu outbreak can easily and quickly kill millions.

Epidemiology has shown us that two important factors are necessary for influenza to kill millions. The first factor is that the specific influenza virus must trigger severe disease. The second factor is that the specific influenza virus must be able to spread person to person.

Influenza also occurs in bird, and pigs, among other animals, and it probably jumped to humans thousands of years ago when they domesticated animals. Various influenza viruses can still jump easily from animals to people. However, when that happens, the disease, which may be quite severe, is self limited. In our increasingly urbanized world, very few people have direct contact with animals. Those who do may pick up dangerous strains of influenza and may die of them, but they won’t pass them on to other people, and no epidemic will develop.

Virology holds the third, and perhaps most important clue. When we think of genetics, we think of offspring inheriting genetic material from parents. Viruses (and bacteria) can exchange genetic material with each other. If both your parents have blue eyes, you might have blue eyes, too. Imagine, though, if you could acquire blue eyes simply by standing next to someone who has blue eyes. Viruses can acquire new traits that way.

The “perfect storm” in the world of influenza viruses is when a virus that is particularly deadly in animals comes in contact with a virus that can easily be transmitted from one human being to another. When that happens, the result can be a new virus that is particularly deadly and is now contagious.

Fortunately, that “perfect storm” does not occur very often, but the possibility always exists that it will happen. The CDC is greatly concerned that the new H1N1 variant of influenza is a “perfect storm” virus. It has the three deadly characteristics that we would expect in such a virus: it is new, so people are not immune to it; it can cause severe illness and death; and it is contagious from person to person.

Viruses can mutate very rapidly. For that reason they can become more dangerous, but they can also become less dangerous. No one knows what is going to happen with H1N1.

So we know the virus is here and the virus is lethal. What should we do about it?

We could do nothing and wait to see what happens. The virus could become less deadly and the danger will be over. Of course, the virus could remain lethal or even become more lethal as it is transmitted from person to person.

You can think about it as if it were a house fire. The fire could burn out of its own accord. It could burn down only the house involved. Or it could jump to neighboring houses and burn them down, too. In fact, fire, like viruses, tends to expand exponentially. It doesn’t jump from one house to the one next door. It jumps to all the houses nearby and then jumps to the all the houses near those. Pretty soon, the entire town is on fire. So waiting to see what happens makes as much sense as waiting to see if a house fire goes out on its own. It means taking a terrible risk.

In the case of viruses, as in the case of fire, prevention is the best strategy. Obviously it’s better if the fire never gets started in the first place. Similarly it is better if no one else gets the H1N1 strain of influenza. Vaccination is the only way to protect people from getting the disease. So vaccination is the first and best line of prevention.

In large fires, firefighters don’t simply attempt to save the houses already on fire. They try to set up firebreaks to prevent the spread of fire before it happens. Vaccination, in addition to preventing individuals from getting sick, also acts like a firebreak. If everyone around an infected person is has been vaccinated, no one can catch the virus. The spread of the virus is stopped cold. Vaccination protects not only those who are vaccinated, but everyone else in the population.

So imagine you are the head of the CDC. You know that H1N1 is here, and it is a particularly deadly form of influenza. You know that it can be passed person to person. And you know from history that similar viruses have killed 10 of millions of people in one epidemic. What would you do? Would you wait to see what happened? Or would you vaccinate against the disease and hope to save lives and halt the spread of the virus?

Doctors are often compelled to make quick decisions in life threatening cases with only limited information. Unfortunately, pregnant women are now going to be put in the same situation.

The H1N1 flu has taken an extraordinary toll among pregnant women. A new vaccine will be available within the next few weeks. Because of the nature of the emergency, there has not been time to do any long term studies of the vaccine. Yet pregnant women will need to make a decision as soon as possible on whether to be vaccinated.

Many illnesses are more severe during pregnancy, but the H1N1 influenza has had an unexpectedly devastating impact among pregnant women. According to the CDC, there have been approximately 700 reported cases of H1N1 in pregnant women since April. Of these, 100 women have required admission to an intensive care unit and 28 have died. In other words, 1 out of every 25 pregnant women who contracted H1N1 died of it. By any standard, that is an appalling death rate.

There seem to be two reasons for the dramatically increased death toll. The first is the altered immune status of pregnant women making them particularly vulnerable to the virus. The second is that pregnancy compromises lung function. If a pregnant woman gets pneumonia as a complication of the flu, it is particularly difficult to insure that she gets enough oxygen.

We should ensure that pregnant women do not get H1N1 influenza and the best way to do that is by vaccination. The new H1N1 vaccine is similar to other influenza vaccines. We know that other influenza vaccines are not harmful in pregnancy, and there is no reason to believe that the H1N1 vaccine will have any side effects that differ from those normally expected after vaccination. There are no adjuvants added to the vaccine, either, so there will be no danger from adjuvants. However, there has been no time to study the long term effects of the vaccine, so no one can be sure about side effects.

Pregnant women are rigorously counseled to avoid any drugs, diagnostic tests, or treatments that might impact the developing embryo or fetus. Most women reflexively fear the idea of vaccination in pregnancy, although vaccination for many diseases presents no problems in pregnancy. The Centers for Disease Control and physicians are very concerned that pregnant women will refuse vaccination, with potentially lethal results.

How should pregnant women decide what to do? The best place to start is with what we know for sure. We have a great deal of evidence that H1N1 influenza is particularly lethal in pregnant women. To put it in perspective, the chance of a pregnant woman dying from H1N1 is greater than the chance of a heart patient dying during triple bypass surgery. That is not a trivial risk.

We have no evidence that the vaccine will cause any harm to pregnant women or their unborn children beyond the side effects associated with other flu vaccines, such as local irritation at the vaccine site, or the rare complication of Gullain Barre Syndrome. We have no reason to expect that the H1N1 vaccine will be any different.

It would be much easier to make the decision if we knew more, if we had some idea of how extensive the fall outbreak will be, if we had longer experience with the specific vaccine. Unfortunately, that information is not available to us and by the time it becomes available may more pregnant women may sicken and die unnecessarily.

Given the dramatic threat and the fact that we know of no unusual complications of vaccination, the decision seems clear. Every pregnant woman should get vaccinated as soon as possible.

The small minority of women who elect to continue Down Syndrome pregnancies have vigorously asserted that the burden of raising a DS child has been exaggerated and that there would be fewer terminations if women were given more accurate information. However, the scientific research does not support those claims and, in fact, demonstrates the opposite.

Physical and Mental Health in Mothers of Children with Down Syndrome by Bourke, et al, was published in the Journal of Pediatrics in September 2008. It showed that mothers of DS children scored lower on measures of both physical and mental health. Indeed, mothers’ the decrease in physical and mental was closely associated with the functional level of the child.

According to the authors:

This study found that the most important predictors of maternal health, particularly mental health, were the child’s behavioral difficulties, the child’s level of everyday functioning, the child’s progress in community participation involving shopping and travel, and to a lesser degree, the child’s current health status…

We found that the mental health of mothers was strongly influenced by child behavior and care-giving demands. These results are similar to studies of psychological stress in caregivers of children with disability or chronic disease… [T]he average mental health score of the mothers in our study was significantly lower than the average score reported for both South Australia and Western Australia. Interestingly, the effect of care giving on maternal physical health appeared less dramatic…

In our multivariate analysis for maternal physical health we showed that mothers of children who scored higher on the disruptive/antisocial subscale of the DBC displayed worse physical health… Our study has corroborated earlier findings that behavior problems are the single most important child characteristic that predicts maternal psychological well-being…

Intellectual disability appears to predispose individuals to emotional or behavioral problems… Eisenhower et al showed at age 3, behavioral problems in children with Down syndrome are comparable to those of typically developing children. However, over the next 2 years there was a relative increase in behavior problems in their Down syndrome cohort and, in turn, maternal stress.

In our study, mothers of children with higher everyday functioning experienced better mental health. In particular, mothers reported better mental health if their children required no help or supervision in dressing, problem solving and, for children over 12 years, using the telephone. Similarly, mothers reported better mental health if their child aged over 12 years required supervision but no help in using the telephone, using public transportation, and attending social events…

These results are hardly surprising. A child’s disability has an impact on the mother’s physical and mental health and that impact is correlated with the child’s level of functioning. Instead of experiencing a DS child as “enriching,” mothers experienced the child as a significant stress, particularly if the child was low functioning. The authors did not investigate the impact of a DS child on marital happiness or the well being of other children in the family. However, it seems reasonable to assume that a stress large enough to impact both the physical and mental health of mothers is likely to have effects that extend to her roles as spouse and as parent to her other children.

None of this is an argument for termination. That is a decision that is and should be left to the mother. However, it is an argument for opposing the attempts of current DS parents to “educate” women facing the termination decision. Those parents who are anxious to “counsel” others are not representative of DS parents and therefore, could not possibly provide unbiased, accurate information.

Sarah Palin burst onto the national scene slightly more than a year ago at the Republican National Convention. Since then she has gone from disaster to disaster: she fatally weakened the Republican ticket, committed countless ethical violations, and couldn’t even manage to govern the State of Alaska. Through it all, she has demonstrated herself to be simultaneously a blithering idiot and a confirmed narcissist.

On the eve of publication of her new book, it is worth examining Palin’s one outstanding talent, her ability to incite hatred. The contemporary GOP is a party fueled on hate. Hate is the stock in trade of O’Reilly, Limbaugh and Beck, so it is no small feat that Sarah Palin could claim to be the hater-in-chief. In her rapturously received speech to the Republican convention she gave what amounted to a clinic in inciting hatred. It is worth looking back at that speech and how she did it.

Psychologists have recently published findings on the five steps in the development of collective hate (Making a Virtue of Evil: A Five-Step Social Identity Model of the Development of Collective Hate, Soc Per Psych Compass 2/3 (2008): 1313–1344) and Palin seems to have embraced the model enthusiastically. According to the researchers:

The five steps are: (i) Identification, the construction of an ingroup; (ii) Exclusion, the definition of targets as external to the ingroup; (iii) Threat, the representation of these targets as endangering ingroup identity; (iv) Virtue, the championing of the ingroup as (uniquely) good; and (v) Celebration, embracing the eradication of the outgroup as necessary to the defence of virtue.

Let’s look at how Palin accomplished those aims.

Identification, or I’m just like you: Palin led with a description of her family, proudly proclaiming, “Our family has the same ups and downs as any other … the same challenges and the same joys.” She emphasized her large family size, her family members in the military, her special needs child, her husband’s blue collar job and her parents’ background as farmer and small business person.

Exclusion, defining the other: Palin was quick to claim that her opponent talks one way in Scranton to working people (us) and another way in San Francisco (them, and they’re gay, too) supposedly deriding religion and gun ownership. Palin invokes the Washington elites (them) as if the Republicans didn’t hold the presidency, vice presidency, Supreme Court, and other major positions of power.

The threat: Her opponent supposedly wants to turn his back on victory in Iraq; her opponent wants us to be threatened by oil producing nations; and, worst of all, terrorists are trying to attack us and her opponent still cares about the Constitution.

Virtue: Her group is uniquely good. She implies that they, and they alone, are the people who care about family, about religion, about patriotism, about sacrifice, and she is sure that God cares uniquely about her group.

Celebration: Finally, the call to action, the insistence that the defeat of the other is required to defend the values of family, religion, patriotism and sacrifice.

Not only was the structure of the speech designed to evoke hate, the very words and the delivery were chosen to ridicule, demean and denigrate. She made is quite clear that her opponents are not merely political opponents, they are people unworthy of the basic respect that should be due to any individual, let alone two Senators who have served their country well.

Sarah Palin was perhaps more honest than she intended to be when she described herself as a pit bull with lipstick. She implied that she is vicious, immoral, bred to attack, and fed on misery and hate. The crowd lapped it up. She carefully followed the script for inciting hatred and the audience responded with thunderous applause. It was a virtuoso performance in the art of hate.

For its fall project, Ms. Taylor’s pre-school class decided to tackle healthcare reform. According to Ms. Taylor, who has taught the Teddy Bear class of three-year olds for the past 20 years, “Instead of drawing autumn leaves and learning the ABC’s, I wanted to try something new this year. And since every American thinks no actual knowledge is necessary to have an opinion on healthcare reform, I thought my three-year olds ought to give it a try.”

Ms. Taylor continued, “You might think that three-year olds would have trouble with a topic like this, but they understood it right away. They were especially talented at issue spotting.” Consider:

No sooner had the dimensions of the problem been explained than little Michelle Bachman, a pert toddler with adorable brown curls, exclaimed, “My healthcare is the bestest healthcare in the world. Everyone else’s healthcare is ugly, ugly, ugly. Only mine is pretty, and it’s mine, all mine.”

Following up on that theme, Rush, a sturdy little boy who spoke while simultaneously knockiing down the building block castle of another child, declared, “I’m not going to share my healthcare with anyone and no one can make me.”

Several children agreed with this sentiment. As little Glen Beck explained, “My mommy says nice boys share, but when I’m holding a toy, it’s mine and I’m not gonna share it. The teacher has to pry it from my cold, sticky hands to let anyone else have a chance. I’m not sharing my healthcare, either.”

There was a bit of a commotion when Ms. Taylor explained to the class that healthcare isn’t free and everyone would need to contribute to making healthcare work. Anne Coulter began to whine, “I don’t want to be a helper. I’m tired. Everyone else should help but not me and my friends. We’re too busy doing other stuff.”

In fact, there was universal agreement on this point. Every child thought that the other children should be helpers, but not them. Being a helper is boring, and that’s not fair.

Suddenly Sarah Palin began to cry. “If I share my healthcare with other kids, they’ll come to my house and take away my toys and my food. And then they’re going to hold playdates without me and plan to kill me.”

When Ms. Taylor tried to explain that no one was going to steal her toys and food, and no one would plot her death, Sarah refused to be consoled.

“No, no, no, they will try to kill me. They’ll hold special playdates to plan it and I won’t be invited. Theyll call them ‘death playdates’.”

When Ms. Taylor tried to explain that some children had no healthcare at all, Dickie Cheney became defiant. “Tough noogies for them. I’m not going to share and you can’t make me.”

Maxie Baucus summed it up best:

“I want the prettiest healthcare in the world, and I don’t want anyone else to have pretty healtchare. It’s not fair if I have to share my pretty healthcare and it’s not fair if I have to do anything to earn it.”

Ms. Taylor proudly reflected on her students’ precociousness. “People often underestimate pre-schoolers” she said. “They think the children are immature, self absorbed and selfish, but I think we’ve proven them wrong today. They exhibited an understanding of healthcare worthy of any member of the GOP.”

Ms. Taylor continued happily:

“We’re planning a field trip next week to our Congressman’s local town meeting. I’m sure others who oppose healthcare reform will welcome the children’s insights.”

The fallout from my post Should we lament the disappearance of Down Syndrome? continues to percolate through the blogosphere. What is striking to me is how the reaction seems to be taken directly from the anti-choice agenda.

The whole notion that parents who elect to terminate a DS pregnancy need to be “educated” bears a more than passing resemblance to the approach of pregnancy “crisis” centers that attempt to talk women out of their decision to abort. The idea that women facing a DS pregnancy don’t understand their options (as if they don’t already know that they could bear the child or give it up for adoption) makes about as much sense as the idea that women seeking abortion don’t understand their options.

The idea that women facing a DS pregnancy can only be “educated” by those who have elected to continue the pregnancy is offensive. The claim that women who have not solicited the advice of strangers should be given the contact information for strangers with an agenda is grossly inappropriate. Those parents are in no more need of the advice of strangers than a woman contemplating an abortion is in need of the advice of strangers.

Although those who support “educating” DS parents claim that they are not anti-choice, the resemblance in inescapable. For me, the most telling behavior is the way that parents who have DS children treat those parents who are overwhelmed by DS children. Only a few such women posted among the more than 400 comments, but the response was alarming and illuminating. Those women who vilified in the most crude and cruel fashion.

If parents of DS children were truly interested in supporting the decision to raise a DS child, they would provide the most support to the people in the most need: people struggling to raise a DS child, and faltering under the burden. I did not detect the least bit of compassion for these women; there was only harsh condemnation.

Inadvertantly, through their reaction, parents of DS children revealed their true agenda. It is not to support those who are raising DS children. It is to vilify those who terminate, bully those who might terminate, and cruelly turn away from anyone who won’t pretend that raising a DS child is “enriching.”

The most common mistakes of alternative health advocates are mistakes of logic. They assume that what “makes sense” to them is automatically true. Thomas Kida, a professor at the UMass Isenberg School of Management, explains why this assumption is unjustified in his book Don’t Believe Everything You Think: The 6 Basic Mistakes We Make in Thinking.

The 6 mistakes are:

Mistake #1: We prefer stories to statistics. Stories are easy to understand; statistics are hard. The problem is that particular stories which may not be representative while statistics, which are merely the aggregation of thousands or millions of stories, offer a realistic assessment of what typically happens. Vaccine rejectionists’ striking reliance on anecdotes shows how alternative health advocates embrace this mistake.

Mistake #2: We seek to confirm our opinions, not challenge them. Homebirth advocacy is a perfect example of this mistake. To my knowledge, there is not a single homebirth advocacy website or publication that contains accurate information about homebirth. Nonetheless, homebirth advocates actually think that they have done “research” simply because they read the opinions of others who agree with them. In contrast, they generally make no effort to read websites and publications by those who offer information that does not support predetermined conclusions.

Mistake #3: Lay people often do not understand chance and coincidence. Most people have no idea of incidence of various risks. They grossly overestimate the chances of rare events and grossly underestimate the chances of common events. Homebirth advocates grossly overestimate the chances of death from a labor epidural, while simultaneously dramatically underestimating the chance of death from homebirth, which is more than a thousand times higher.

Mistake #4: Our personal perceptions about what is happening are often wrong. Unfortunately, the level of confidence in our perceptions is often entirely unjustified.

Mistake #5: We tend to oversimplify our thinking. Oversimplification is easy; reality is hard. While some simplification is necessary, particularly for lay people when first learning about complicated concepts, we must always keep in mind that simplification introduces distortions. Simplification is the merely the first step in thinking about complicated issues. It does not lead us to correct conclusions.

Mistake #6: Our memories are often inaccurate. This has actually been studied quite extensively. People tend to alter their memories to create a “narrative” that makes sense to them. Reality is not a narrative, however.

These mistakes are a vestige of the thinking processes that served us well in the hundreds of thousands of years of evolution in the wild. Statistics did not exist, so stories were the best way that we had to understand the world around us. Our perceptions were all we had available to us, and oversimplification is almost always the first step to understanding. In other words, there was a time when reasoning from what “makes sense” was the only thing that we had. Now those methods have been superceded by other, more accurate methods, but some people are still stuck in the past.

The typical homebirth advocate, or the typical vaccine rejectionist, does not know about or does not understand the new, more accurate methods for evaluating the world around us. They revert to more “primitive” forms of reasoning because they literally do not know any better.

This post originally appeared on Homebirth Debate in May 2008

During my years of medical training I learned about the many causes of illness, but evidently that understanding is outmoded. Sophisticated Americans know that illness is a choice. People bring it upon themselves by their own choices. This new understanding is incredibly liberating. No need to feel sorry for people who are sick because it is their own fault. No need to provide healthcare, since poor health is attributed to bad choices. Best of all, no need to worry about getting ill. If illness is a choice, all you have to do to stay healthy is slavishly follow the socially mediated goals for weight and exercise, and nothing bad will ever happen to you.

Unfortunately, illness is not, by and large, amenable to choice. The new understanding of healthcare, what everyone knows to be true, is that diet and exercise are magically protective, that preventive medicine is the only medicine that counts, and that illness is a sign of slovenliness and lack of self-discipline. This new understanding tells us more about the psychological needs of the people who believe it than it tells us about health and disease.

Only a small fraction of illness is caused by lifestyle choices. The leading cause of disease is aging. The wear and tear on the human body inevitably leads to breakdown, whether the breakdown is physical or cognitive. No one chooses to get shingles, suffer from Alzheimer’s or to succumb to diseases like the flu that would be far less serious in younger adults.

Infectious diseases, caused by viruses or bacteria, are not amenable to choice, either. Viral or bacterial illness is usually caused by nothing more than being in the wrong place at the wrong time, being exposed to an illness that someone else has. Fortunately, preventive care for infectious diseases is highly effective. It is called vaccination and it saves ten of thousands of American lives each year.

Some diseases are genetic. These include diseases with obvious genetic causes like sick cell anemia or Huntington’s Disease, but other diseases like cancer almost certainly have a genetic basis, too. That genetic basis may be a propensity to develop the disease through mechanisms that we do not yet understand. It is likely to turn out that cancer, auto-immune diseases, and even heart disease are mediated by our genes.

It is true that some lifestyle choices behaviors impact the chance of developing illness, in particular smoking, drinking to excess and eating to obesity. Yet it is far from clear that even these behaviors are entirely amenable to choice.

Many of the worst excesses are the result of addiction. People do not make a conscious choice to become alcoholics or drug addicts. Yes, the decision to drink for the first time or to use drugs for the first time is a choice, but being gripped by addiction is not a choice at all. Indeed, there is some evidence that there is a genetic predisposition to addiction. While most people can drink alcohol without any permanent effects, alcoholics have a different reaction, one that leads to an inability to stop drinking.

Even making the choice to engage is a behavior known to be harmful does not mean that one has chosen to become ill. Most people who smoke don’t get lung cancer, and many people addicted to tobacco assume that they will avoid that dreadful outcome; they certainly don’t choose to get lung cancer.

The bottom line is that there is no evidence that illness is a choice. So why do many people persist in believing that it is a matter of choice?

It’s not difficult to understand their rationale. If illness is a choice, then they can choose not to be ill. If illness is a matter of failing to meet socially mediated goals for weight and exercise, staying healthy is easy: just meet those goals by dieting and exercising. In addition there’s need to feel sorry for people who are sick because it is their own fault. And there’s no need to provide reform the healthcare system, since poor health is attributed to bad choices.

Pretending that illness is a choice minimizes both fear and guilt. Sadly, it is nothing more than wishful thinking.

According to The Wall Street Journal, Novartis is developing a system that reminds patients to take their medications.

The company is testing inserting tiny microchips into the pills as part of a system that tracks whether patients are taking their meds as prescribed. When patients veer off course, they get a text message reminder.

The technology has significantly improved adherence in a very small group of patients taking the company’s blood pressure medicine Diovan …

The benefits of this technology could be huge. Patient compliance is a very serious issue, and anything that promotes compliance is likely to improve health. But the technology has disturbing implications that we ought to explore before it is widely implemented.

Bioethicist Summer Johnson points out:

…The tiny little microchip inside the medication would monitor one’s blood level and when it slips too low it sends a message to the patient saying, “Hey dude, time to take your medication!” It’s efficient, simple, and could potentially save your life. No complaints here, right?

Wrong! This invades patient’s privacy and a patient’s right to be delinquent taking medication and screwing up their dosing. It makes it much more difficult for patients to ignore doses or to say, “If I don’t want to take medication, I don’t have to” with a microchip inside their body beaming out text messages to a device annoying them all the time. Particularly if that device can send its data to their physician or worse yet to their insurance company reporting them as a non-compliant patient.

Dr. Johnson dismisses these concerns:

But isn’t that the point? To motivate patients to be compliant? Personally, I think the more we can do to encourage chronic disease management that actually works and compliance with long-term dosing regimens that work, the better.

If this drug can actually do what it promises, I hope they make more of them.

I am surprised at that response. Didn’t we learn in ethics 101 that the ends do not justify the means? Although the goal is admirable, the privacy concerns are real and should not be dismissed out of hand.

The technology could represent a substantial benefit for patients who want help remembering to take their medications. Individuals suffering from complex medical conditions and elderly patients often have difficulty remembering to take medications that they fully intend to take. No doubt those patients would appreciate the reminder, and might also appreciate the fact that their doctor (and family) could be notified if they forget to take a particular medication.

Most of us, though, could buy a simple pillbox alarm if we felt we needed help remembering to take medication. It is not clear if there is any additional benefit to the micro-chip technology and there are substantial privacy concerns.

Taking medication is a personal decision. Although I as a doctor may lament the fact that some patients are non-compliant, should I employ tools to guarantee compliance? Should doctors be receiving minute-by-minute information on patient behavior? Should insurance companies have access to this information? Should they be allowed to terminate coverage if they learn that patients have not taken each and every recommended pill as directed.

Inserting micro-chips into medication is a form of surveillance. And as with any type of surveillance, the argument can be made that you have nothing to worry about if you are not doing anything wrong. Yet the police are not allowed to put cameras into people’s houses to make sure they are behaving behind closed doors. That’s because we value the right to privacy. That right to privacy should extend to medical decisions like whether or not to take blood pressure medication on time, or whether to take it all.