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February 14, 2017

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anon

Steve

I agree with this post. The term suggested strikes me as appropriate, and I couldn't agree more that it is a necessary addition to the medical establishment's lexicon in appropriate circumstances.

anon

Re: update

Bravo!

A little humility and self-awareness, combined with an open mind, is always a good thing.

Patrick S. O'Donnell

Of course a disease or illness can be both, psychosomatic and biomedical. In the case, say, where an illness might be psychosomatic in origin, there need be no reason to rule out biomedical treatment (unless of course we’re devoted to the genetic fallacy), as we still know so little about the actual origins or first causes, as it were, of many illnesses to proclaim that biomedical pathways don’t have psychosomatic beginnings or psychosomatic entanglement (this need not, on the other hand, implicate someone in the claim that unexplained causes of symptoms are necessarily psychosomatic). Consider, for example, the discovery that “the biological responses to stress-inducing situations were ameliorated by the strength of the social support provided by other people considered as being important by the individual” (a psycho-social variable of considerable significance). And I suspect even biomedical prescriptions and therapies often work best in tandem with something like, if not actually, the “placebo effect,” or at the very least, “wishful thinking” or perhaps a “self-fulfilling prophecy” (which are thus not always liabilities).

Moreover, the fact that the foremost premises and informational design of medical care and public health has been in the main biomedical, in other words, has been wedded to a biomedical theory of causation and distribution of disease, has led to counterproductive and needless constraints in explaining diseases, as evidenced in its inability to “explain fully the causation of diseases most prevalent in developed economies, namely chronic and degenerative conditions.” (Even outside that context, epidemiology is found wanting, as in the case of identifying the risk factors for heart disease, the totality of factors accounted for explains, roughly, only 40 percent of the cases, leading some epidemiologists to wander if there has been a systematic failure to account for surrounding environmental influences, for unless we subscribe to genetic determinism, it’s certainly possible if not probable that we have a case here of the environment (in the widest sense) influencing how genes express themselves.) The prevailing model of epidemiology (increasingly questioned from within and outside the field), which “evolved from the late nineteenth-century germ theory of disease, recognizes three categories of causal factors:” “biological endowments, behaviours and external exposure to harmful substances or ‘agents.’” This model operates at the level of the individual, what we might term “explanatory libertarianism” (my locution), as it confines causal pathways to the individual human body, precluding the recognition of “any supra-individual level factors or social processes as part of the longer causal chain in the production of disease.” Not surprisingly populations are thus merely a “collection of individuals,” public health being the sum total of the health of those individuals.” The conspicuous problem here is that “the inability to group individuals according to social features precludes the model’s ability to analyse the possible causal impact of social conditions.”

A seminal study by Richard Wilkinson pioneered a research agenda providing evidence for the proposition that “higher income inequality in societies correlated with lower population average health and higher social inequalities in health,” moreover, below a certain threshold, “absolute material deprivation has more significant influence on mortality and health outcome than income inequality.” In brief, “[a]cross a number of industrialized countries, and within regions of countries, Wilkinson’s analysis shows that the steepness of the health gradient is associated with level of income inequality.” (Alas, and ceteris paribus, that mean so many of Trump’s white working class supporters will probably die before he does.) Intriguingly, Wilkinson’s work is not necessarily only about the so-called materialist determinants of health, but may suggest the “psychosocial effects of being of lower social status, experiencing subordination, or being denied respect.” There are other explanations (some having to do with ‘political economy’) to account for Wilkinson’s findings, but the results of an emerging field of “social epidemiology” are both sobering and promising, although it’s a lamentable fact that “most of the research about the social determinants of health has been done in developed economies.” The quoted material above is from Sridhar Venkatapuram’s very important book, Health Justice: An Argument from the Capabilities Approach (Polity Press, 2011).

The following passage from Richard W. Miller’s unduly neglected (inferred from the comparatively few references found in the literature), Fact and Method: Explanation, Confirmation and Reality in the Natural and Social Sciences (Princeton University Press, 1987) goes to the heart of the issue:

“In the organized pursuit of explanation, practical concerns may … dictate choice of a standard causal pattern. In the early nineteenth century, many investigators had come to explain the prevalence of certain diseases in certain places as due to filth and overcrowding. For example, the prevalence of tuberculosis in urban slums was understood this way. In these explanations, the microbial agent was not, of course, described. But the causal factors mentioned were actual causes of the prevalence of some of those diseases. _If Manchester had not been filthy and overcrowded, tuberculosis would not have been prevalent._ On the purely scientific dimension, acceptance of accurate environmental explanations probably did not encourage as many causal ascriptions as would a standard requiring explanation of why some victims of filth and overcrowding became tubercular, some not. Those who pressed the latter question were to lead the great advances of the germ theory. But _in a practical way, the environmental explanations did a superior job, encouraging more important causal accounts. Guided by those accounts, sanitary measures produced dramatic reductions in tuberculosis and other diseases, more dramatic, in fact, than the germ theory has yielded._ A perspicacious investigator might have argued, ‘We know that some specific and varied accompaniment of filth and overcrowding is crucial, since not every child in the Manchester slums is tubercular. But we should accept explanations of the prevalence of disease which appeal to living conditions. For they accurately, if vaguely, describe relevant causal factors, and give us the means to control the prevalence of disease.’” [emphasis added]

Consider too, the argument from a recent article in the New Left Review 102 (Nov/Dec 2016):

“Policies aimed at re-engineering local economics for the benefit of mul­tinationals have had a drastic impact on landscapes and ecosystems, and thus upon the fortunes of infectious disease. As epidemiological history attests, context is more than just a stage upon which pathogens and immunity clash. The regional agro-economic impacts of global neoliberalism can be felt across the levels of biocultural organization, down as far as the virion and molecule. The exploration of such connec­tions may well be a cutting-edge question for the twenty-first century. A growing public- and animal-health literature suggests that current pat­terns of agro-economic exploitation raise the risk of a new pandemic, whether triggered by an RNA virus like Ebola or SARS, or by some other pathogen. Ecosystems in which ‘wild’ viruses are controlled by the rough-and-tumble of environmental stochasticity are being drastically streamlined by deforestation and plantation monoculture. Pathogen spillovers that once died out relatively quickly are now discovering chains of vulnerability, creating outbreaks of greater extent, duration and momentum. There is a possibility that some of these outbreaks may come to match the scale of 1918’s influenza pandemic, with a global reach and high rates of incapacitation and mortality.

Capitalist agri-business is increasingly transforming Planet Earth into Planet Farm. Forty per cent of the world’s land surface is now dedicated to agriculture, with many millions more hectares set to be brought into production by 2050. Livestock, representing 72 per cent of global animal biomass, is simultaneously highly concentrated and widely dispersed across the planet’s surface. The livestock sector uses a third of available freshwater and a third of cropland for feed. By its global expansion, com­modity agriculture acts as a nexus through which pathogens of diverse origins migrate from even the most isolated reservoirs in the wild to the most globalized of population centres. The longer the associated sup­ply chains and the greater the extent of deforestation, the more diverse (and exotic) the zoonotic pathogens that enter the food chain. Among such emergent pathogens are industrial Campylobacter, Nipah virus, Q fever, hepatitis E, Salmonella enteritidis, foot-and-mouth disease and a variety of novel influenza variants. Intensive agriculture’s diseconomies of scale extend beyond the unintended epidemiological consequences of globalizing transport and distribution. Its production cycles degrade the resilience of ecosystems to disease, and accelerate pathogen spread and evolution by giving rise to genetic monocultures, high population densities and expanding exports. In this essay, we describe the emergence of an urbanized Ebola in West Africa in late 2013 as a quintessential example of such a transition.”

It seems we need a term for the failure of health care researchers and professionals to appreciate the “social determinants” of health.

Suggested Reading:
• Anand, Sudhir, Fabienne Peter, and Amartya Sen, eds. Public Health, Ethics, and Equity. New York: Oxford University Press, 2004.
• Asthana, Sheena and Joyce Halliday. What Works in Tackling Health Inequalities? Pathways, Policies and Practice through the Lifecourse. Bristol, UK: The Policy Press/University of Bristol, 2006.
• Bhopal, Raj S. Ethnicity, Race, and Health in Multicultural Societies: Foundations for Better Epidemiology, Public Health, and Health Care. New York: Oxford University Press, 2007.
• Chapman, Audrey R. Global Health, Human Rights and the Challenge of Neoliberal Policies. Cambridge, UK: Cambridge University Press, 2016.
• Daniels, Norman. Just Health: Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press, 2008.
• Derickson, Alan. Black Lung: Anatomy of a Public Health Disaster. Ithaca, NY: Cornell University Press, 1998.
• Farmer, Paul. Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, CA: University of California Press, 2003.
• Farmer, Paul, et al., eds. Reimagining Global Health: An Introduction. Berkeley, CA: University of California Press, 2013.
• Frumkin, Howard, ed. Environmental Health: From Global to Local. San Francisco, CA: John Wiley & Sons, 2016.
• Hatch, Anthony Ryan. Blood Sugar: Racial Pharmacology and Food Justice in Black America. Minneapolis, MN: University of Minnesota Press, 2016.
• Kawachi, Ichiro and Lisa F. Berkman, eds. Neighborhoods and Health. New York: Oxford University Press, 2003.
• Kawachi, Ichiro and Bruce P. Kennedy. The Health of Nations: Why Inequality is Harmful to Your Health. New York: The New Press, 2006.
• Kawachi, Ichiro and Sarah Wamala, ed. Globalization and Health. New York: Oxford University Press, 2007.
• Kawachi, Ichiro, S.V. Subramanian, and Daniel Kim, eds. Social Capital and Health. New York: Springer, 2008.
• LaVeist, Thomas A., ed. Race, Ethnicity, and Health. San Francisco, CA: Jossey-Bass/John Wiley & Sons, 2002.
• Leon, David and Gill Walt, eds. Poverty, Inequality and Health: An International Perspective. New York: Oxford University Press, 2001.
• Levy, Barry S. and Victor W. Sidel, eds. Social Injustice and Public Health. New York: Oxford University Press, 2006.
• Marmot, Michael and Richard G. Wilkinson, eds. Social Determinants of Health. New York: Oxford University Press, 2nd ed., 2006.
• Navarro, Vicente and Carles Muntaner, eds. Political and Economic Determinants of Population Health and Well-Being. Amityville, NY: Baywood, 2004.
• Stuckler, David and Karen Siegel, eds. Sick Societies: Responding to the Global Challenge of Chronic Disease. New York: Oxford University Press, 2011.
• Venkatapuram, Sridhar. Health Justice: An Argument from the Capabilities Approach. Malden, MA: Polity Press, 2011.
• Wallace, Rob. Big Farms Make Big Flu: Dispatches on Influenza, Agribusiness, and the Nature of Science. New York: Monthly Review Press, 2016.
• Wallace, Robert G. and Rodrick Wallace, eds. Neoliberal Ebola: Modeling Disease Emergence from Finance to Forest and Farm. Cham, Switzerland: Springer International, 2016.

For a more comprehensive list, please see my bibliography: “Health: Law, Ethics & Social Justice,” available on my Academia page.

anon

after 1900 words, and over twenty references on the reading list, the conclusion is:

"It seems we need a term for the failure of health care researchers and professionals to appreciate the “social determinants” of health."

In other words, with respect to Lubet's post, the point seems to be (confess, who could actually read all that?) "agree."

Patrick S. O'Donnell

I believe (perhaps naively or mistakenly), and certainly hope, that there are at least some Faculty Lounge visitors who are capable of reading (and not afraid to learn therefrom). I well realize that in the age of twitter and texting, the ability to read and comprehend more than a few hastily composed messages may be a vanishing skill or art.

I'm not persuaded that the definition of an "iatromoric diseases [a]s one that fools, confounds, or baffles ... doctors" adequately captures the problem insofar as a physician well-versed in the relevant albeit fairly recent epidemiological (and social-scientific) literature covering the social determinants of health will not be so easily fooled, confounded, or baffled. This may include a concern with "discovering and respecting the patient's real interests," entailing in part an appreciation of "widely different life stories and the role of illness in those stories." In addition, this involves doctors and other health care workers cultivating an ability to "locating the silences" in a clinical setting, silences that are "endemic to human suffering. The first is found where there are gaps in a person's psychological life, and the second is imposed by the medical setting and its legitimated discourses." (Grant R. Gillett)

anon

That's right. What we need is politically correct, sensitive doctors. Doctors who can diagnose "silence" and who can discern and treat the "gaps in a person's psychological life."

Anyone who has known doctors in their private lives knows how hopelessly naïve these statements truly are. Doctors struggle to competently treat their patients up a very minimal standard. If you want a reading list, start reading about the number of lives lost every year because of physician malpractice.

The start for the medical community is to acknowledge deep and abiding gaps in its skill level and knowledge, its frequent inability to treat the most basic and common illnesses, and its gross ignorance about so many of the root causes of the symptoms at which it is so inclined to throw life long pharmaceutical treatment (often is accompanied by dire side effects that make the patient sick, just in a different way).

And, you propose turning doctors into amateur psychiatrists? How's that working out now, with the real psychs? Please.

"Life stories" is just another cover for the identity politics that is so often peddled here in the FL. Is there NO subject that can't be infected by this poisonous outlook?

Enrique Guerra Pujol

I second the sentiments of anon. And I would add that there is no linear relation between "truth" and the number of words amor number of sources cited. This is a blog for goodness sake, not a repository for policy papers.

Patrick S. O'Donnell

Who claimed or implied there was "a linear relation between 'truth' and the number of words amor [sic] number of sources cited"?

I know what a blog is: I write for the Agricultural Law blog, the Ratio Juris blog (close to 10 years now), and Religious Left Law (about 7 years) (links to the latter two at left on this page), and have routinely commented at a number of law blogs (e.g., Opinio Juris, Dorf on Law, PrawfsBlawg, Legal Ethics Forum, etc., for well over a decade now). If you think the above is akin to a "policy paper" I suspect you're in the dark about what constitutes a "policy paper."

If you don't want to read a comparatively long comment (or are afraid of learning something), don't read it.

Patrick S. O'Donnell

WARNING: This comment has more than 140 characters

By the way, the statement above about “life stories” simply being a “cover for...identity politics”* reveals complete ignorance of the relevant literature and its arguments (from those inside and outside the medical community, philosophers included in the latter category) are discussed and elaborated. Professor Grant Gillett, at once a medical ethicist, philosopher, and neurosurgeon, has two books that are essential reading should one care to appreciate the sophistication of arguments on their (i.e., narratives in a clinical setting) behalf: Bioethics in the Clinic: Hippocratic Reflections (Johns Hopkins University Press, 2004) [the title is misleading insofar as the book is some distance from prevailing conceptions of bioethics], and Subjectivity and Being Somebody: Human Identity and Neuroethics (Imprint Academic, 2008) [in this case, the subtitle is misleading to the extent that his understanding of ‘neuroethics’ is completely shorn of what another doctor and philosopher, Raymond Tallis, has termed ‘neuormania’]. While worldviews (which are far wider in scope than political ideologies) may play a role in life stories, they’re individuated as ‘lifeworlds,’ which accords them a poignant personal or biographical dimension that is not part of what is typically meant by “identity politics” (in a pejorative or non-pejorative sense). Recently, another philosopher, Daniel Hutto (Professor Philosophical Psychology specializing in psychology and philosophy of mind), has written a wonderful essay, “Narrative Practices in Medicine and Therapy: Philosophical Reflections,” which I highly recommend to those with even the slightest interest in this topic (it is available on his Academia page).

Doctors and nurses, as well as other health care professionals are given basic training in psychology, some of it mandated by Federal rules and standards, particularly by way of initial screening of patients, and this is an unmitigated good development, with no intent or result that suggests these health care professionals are becoming (or aspiring to become) “amateur psychiatrists.”

Anon’s awkward comment about the “medical community” “inclined to throw life-long pharmaceutical treatment,” could be re-worded to refer to an ongoing problem exacerbated by Big Pharma and the capitalist nature of our health care system. Once more, should anyone care to acquaint themselves with the relevant literature, you can visit my Academia page and scroll down to the bibliography on “Biological Psychiatry, Sullied Psychology and Pharmaceutical Reason.”

Finally, physician malpractice is not, comparatively speaking, much of a problem, what is a problem are the many patients who have unrealistic expectations about being “cured” of certain kinds of illnesses, or relieve of all their pain and suffering, particularly inasmuch as health outcomes may require significant changes in personal behavior, a change in the color of one’s skin, or significant upward socio-economic mobility (or perhaps all three). What is a problem is the cost of medical malpractice insurance for physicians. For one incisive essay that covers several facets of this subject, please see Atul Gawande’s “The Malpractice Mess” in The New Yorker (Nov. 14, 2005).

* For a fair and uncommonly incisive appraisal of the virtues and vices and “identity politics,” please see Kwame Anthony Appiah’s now classic treatment, The Ethics of Identity (Princeton University Press, 2005).

Patrick S. O'Donnell

erratum (first sentence) "...the relevant literature and how its arguments (from those inside and outside the medical community, philosophers included in the latter category) are discussed and elaborated.

anon

SEe, e.g., the Washington Post,

Researchers: Medical errors now third leading cause of death in United States, By Ariana Eunjung Cha May 3, 2016

This fact is confirmed by study and study, all by reputable sources.

Speaking of "unrealistic expectations," how about a 1900 screed, including a reading list - that would take easily months to complete - simply to "comment" about a blog post proposing use of a term to describe a condition in modern medicine?

If the accuracy of this statement is any indication - "physician malpractice is not, comparatively speaking, much of a problem" - then no thanks. I'll pass on the lecture and the course, and will, as suggested simply scroll past the diatribes.

BTW, there is a difference between a tweet and a 1900 word piece.

anon

Post

LOL about the doctors gaining all these "life stories" and "life worlds" and "nurses, as well as other health care professionals [having] basic training in psychology."

Anyone familiar with the current clinical setting in medicine knows how wildly absurd are these concepts. Any person pontificating about these deep, insightful encounters on the basis of what is likely a very twisted version of scholarly imaginings hasn't a clue about the average time per patient, content of the communication, quality of the observations, etc.

Again, the medical community struggles to meet the existing, minimal standard of care.

Patrick S. O'Donnell

While it is anecdotal evidence, it confirms research and arguments made by others: I have some familiarity with the current clinical setting in medicine apart from my own experience of well over 50 years, with numerous family members and friends (and more than a few of my neighbors) working in health care, and they've never characterized this material, these ideas or concepts, as "wildly absurd," indeed, nothing remotely close to such a description.

Physician malpractice is not equivalent to the errors identified in the research you cited, as it involved health care at hospitals: "researchers caution that most of medical errors aren’t due to inherently bad doctors, and that reporting these errors shouldn’t be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability." As for the type of errors identified here, I've learned of these in the form of vivid first-hand accounts from several individuals near and dear to me.

Whether a reading list takes days, weeks, months, or years to complete is utterly beside the point. You are clearly intimidated, that's fine; and as for the difference between a tweet and and my post, I would not have known had you not informed me: a sense of humor might help here.

Patrick S. O'Donnell

RE: "Any person pontificating about these deep, insightful encounters on the basis of what is likely a very twisted version of scholarly imaginings hasn't a clue about the average time per patient, content of the communication, quality of the observations, etc."

Thank goodness you weren't referring to yours truly, as I cited just two of many examples of physicians writing about these matters (and I have numerous others in my bibliography, 'Health: Law, Ethics & Social Justice'). And you might have shared your academic or professional expertise by way of explaining how you arrived at the judgment that "these" are "likely a very twisted version of scholarly imaginings."

Please have the last word, as this has grown tiresome from my end.

anon

Patrick

One would think you are indefatigably superior, based on the tone and content of your "comments."

You distinguish between deaths caused by medical errors and "medical malpractice" because the former are "systemic problems, including poorly coordinated care, ... the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability" but the latter result in "legal action." No need to rebut that bit of reasoning.

The point here is that, despite your bold, unqualified claim above that "physician malpractice is not, comparatively speaking, much of a problem" you are completely unable to refute the evidence that "Researchers: Medical errors now third leading cause of death in United States, By Ariana Eunjung Cha May 3, 2016." I say that makes what you claim unreliable.

In that context, you now claim, based on the fact that you know some people who work in this field and you read two articles by physicians, that you are able to state without any equivocation that doctors have the time to engage in exploring " "life stories" and "life worlds" because "nurses, as well as other health care professionals [have] basic training in psychology."

Most offensive to me is that you are propounding these demonstrably absurd notions (that doctors treating illnesses have the time or the ability to relate "life stories" to the diagnosis and treatment) because you believe that categorizing people is the way to deal with every issue. Doctors should not be categorizing people based on race, religion, ethnicity or like criteria unless medical science shows a reason to do so. THis is exceedingly rare: but you apparently would have it done in every case.

As for the conceit that posting reading lists is actually necessary and useful, I would suggest that you adopt a bit of the humility referenced above. If you are not arrogant, you might see some truth to the point that a 1900 word essay with a reading list suitable for a semester, not a comment on a blog, is not really useful to make your points.

Enrique Guerra Pujol

Postscript for Patrick (if I may): I really like your "ratio juris" blog; I'm going to read your natural law paper later this week and will revisit your blog and send you my thoughts there soon ...

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