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Saturday, December 10, 2011

"Irrational" personal fears and impact on others

I read about many things; economics, history, psychology, medicine and politics to name but a few. I also interact with a variety of people, including patients, within multiple contexts. From my reading and personal experiences, I am beginning to see common themes which cut across my own experiences and narratives of others relating to fears and risks, the decisions which come as a consequence of the impact of these perceptions, and the consequences of those decisions.

Matt Ridley wrote a piece in today's WSJ entitles "Why deny biotech to hungry Africa? The gist of the piece was that there is a disconnect between the immediate food needs of hungry African populations and the concerns of generally well fed environmentalists about the possible long-term ramifications of introduction of genetically modified (GM) crops. I find it nothing short of amazing (and frankly indefensible) that we have not deployed the available tools to increase crop yields in places where people are starving (not to mention mandating turning foodstuffs into fuel). The question is what are the elites who are controlling these decisions afraid of? 

I think the answer is they are more afraid of something that might happen in the future than they are of the immediate and more definable consequences of their decisions in the present. For the most part, those making these decisions are not eking out an existence and their decisions, which affect millions of hungry people living on the edge of subsistence, and driven by their anxiety of some future events, politics, and self interest. Is it really a decision that is in the best interest of those who are most vulnerable? Would they make the same decision if they and their families were hungry? 

What should be their priorities? I should not totally discount their anxieties about the future. However, weighing the present vs. the future should always be examined through the lens of the magnitude of present problems, the likelihood that immediate action with provide relief, how likely unintended consequences from the action might be, and the likelihood that other trends outside of human control will dwarf any human driven effects. In the case of GM modified crops, the recent track record is consistent. Where they have been deployed, their effects on the human condition are positive. Food is more abundant and cheaper. I see this in nothing but a positive light.

 How likely are catastrophic consequences? No one knows, not even within orders of magnitude. However, mankind has been manipulating animals and crops for thousands of years. As man moves into areas and exploits the environments, they evolve. We carry both GM and non-GM entities into places where they did not exists before. This included kudzu into the South, lampreys and tiger mussels into the Great Lakes, wild pigs into North America to name but a few. Yes, the world was altered. No, it did not come to an end. This all happens on a long term background of continents moving, climate changing, and occasional asteroid impacts. 

I look at this scenario and I see similar themes in the delivery of health care. We are faced with the health needs of patients and have limited resources to deploy to address those needs. Like the hungry people of Africa who have immediate needs, we have no shortage of people who are suffering directly from the effects of illness. They are in pain, are short of breath, have limited mobility, are depressed, or are limited in some way by their illness in the here and now. 

Simultaneously we have those entrusted to make sure that tools we deploy in the present do not have some major unintended consequences in the future. This can exist on both the macro level and the micro level. On the macro level we have entities such as the FDA, which is rarely rewarded when they have facilitated access to drugs and are absolutely hammered when small numbers of patients are harmed, even when the events are completely unforeseeable.  Much like the divergent goals of affluent environmentalists and poor African farmers, the goals of the FDA and of patients suffering with disease are poorly aligned. They are influenced by different circumstances and different fears that create different incentives. 

At the micro level, the same scenarios play out when patients and physicians interact. My own experience as a physician is that we often are not able to distinguish our personal goals and fears from the actual patient goals and fears. We avoid taking personal risks, even when it means we become ineffective at addressing immediate suffering of patients. We discount patient fears when they are not our own fears. We fail to acknowledge that some of our own fears are irrational and patients should discount them. We end up depriving needy patients of interventions that can effectively deal with their immediate needs because of our own fears (often irrational) and our own self interest disguised at best as paternalistic protection of the world in general. 

There is a very fundamental issue beneath all of this. Where should our primary focus lie as healers? Should we be primarily focused on immediate suffering or should we be more focused on attempting to influence events well in the future? My own bias is we should be more focused on the former. There is no shortage of people who have immediate medical needs and the success or failure of our interventions can be more readily determined. When our actions are driven by possible events well into the future, it becomes more and more difficult to assess whether any of our activities have any value whatsoever, except for the immediate financial consequences. Grandiose schemes to change the future world make us feel good about ourselves and great marketing copy. I prefer to deal with the immediate needs of individual patients (even if it means some taking personal risks) and leverage my activities by being involved in the training of students and residents who hopefully will model only the best of my behaviors. 

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