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Sunday, February 23, 2014

Do you like surprises?

I sometimes wonder what the future will bring in terms of surprises. Specifically, I wonder about what we (I) am doing now which will be considered unacceptable and undesirable at some point in the future. At the same time, I also wonder about what is now considered unacceptable which will become mainstream in the not too distant future.

Two hundred years ago there were many practices and beliefs which were mainstream and strongly held which have now been jettisoned. The one that comes to mind is slavery of African Americans. Slavery was accepted for thousands of years and is likely still accepted in many parts of the world. However, over the span of approximately 200 years, the moral climate the western world rapidly evolved from one where slavery was an acceptable practice to one where it is universally deplored. Similarly, custom backed up by law was used for centuries to restrict the freedom and actions of people based upon their sex, religion, ethnic group, or status at birth. All of this was viewed as being perfectly acceptable within the cultures where it
occurred, until it was no longer viewed that way.

It can be viewed as something which is part of a broader set of events. The tendency for human cruelty, at least within public realms appears to have receded. Yes, I can still tune into broadcasts of ultimate fighting and fans still celebrate fights on the ice in hockey, but this sentiment gets less acceptance over time. Similarly, people and organizations which celebrate hate, violence, and intolerance now function primarily at the margins of our society.  This trend is not something which is universal in the world. It is more the exception rather than the rule. Slavery still exists. Surprisingly, the world is purportedly less violent than at any other point in human history (Violence Ted Talk). However,  it is till plenty violent. One can hope that the tendency toward less cruelty continues.

What are we doing now which we will look back on with with great remorse? In the medical world, our behavior in regards to informed consent as recently as 50 years ago was absolutely deplorable. I have written about the syphilis experiments at Tuskegee and Guatemala, studies which survived study section reviews. The medical community had great enthusiasm for eugenic thought (Cold Spring Harbor). We physicians perceived that since our intentions were good, we should be empowered to recommend and do almost anything without judgment. The explosion of information now available to the public regarding medical decisions and recommendations is disrupting this process and will shine lights on specific decisions and recommendations. Difficult questions will be raised and more than a little embarrassment will follow. Public trust will degrade even more and more time will be required to explain our recommendations.  We will likely stop doing certain interventions, I am not sure what they might be.I perhaps am as blind as anyone. I will be surprised.

The flip side to all of this is we can also anticipate that there are current unacceptable activities which will be viewed as perfectly reasonable in the future. Up until the very recent past, racial intermarriage and homosexuality were considered unacceptable and in many locales, illegal. What do now view as reprehensible and unacceptable behavior which will be viewed with a ho-hum in the next 50 years? I am not hedgehog. I readily admit that my predictions are likely to be off the mark.  I suspect that pot will be legal and widely available within the next 20 years. I also suspect that the acceptance of gay marriage will open a wider discussion regarding the institution of marriage. Polygamy will be the next issue raised and in the absence of any strong legal framework to continue this prohibition, it will fall. This will lead to havoc in the legal realm, trying to sort out benefits due to those who had some sort of marriage arrangement to some other party, separated by death or some other circumstance. The like the legal simplicity of heterosexual monogamous unions for the simple reason that this will be replaced with a host of potential relationships with daunting combinatorial math of possibilities. More surprises on the way.

Within the health care realm, new possibilities of acceptable options for how we behave and organize may take the form of new providers of health care services. Our present health care organizational structure is held in place by law preventing new entrants into the game. How long will this hold together? The fortress that is the state medical licensing barrier has shared only pieces of  the health care business to optometrists, chiropractors, nurse practitioners, physical therapists, podiatrists, psychologists, social workers, and other therapists who can operate autonomously or semi-autonomously. Physicians still use the power of law to prevent entry of others into the health care arena, ostensibly to protect the public. If history of change  is consistent over time, this structure will also be viewed as the norm until the day it is not. It is a matter of time. This should not surprise anyone.

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