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10 Controversial Medical Questions Answered by Dr. Dalrymple

Where do you stand on these challenging ethical and scientific debates?

by
Theodore Dalrymple

Bio

March 15, 2014 - 8:00 am
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From October 2012:

4. Do doctors turn their patients into drug addicts?

Prescription is quick and lucrative, while encouraging the patient to forego his drugs is difficult, time-consuming and ill-paid.

When I was a young doctor, which is now a long time ago, patients who were close to death were often denied drugs like morphine for fear of turning them into addicts during their last weeks of earthly existence. This was both absurd and cruel; but nowadays we have gone to the opposite extreme. We dish out addictive painkillers as if we were doling out candy at a children’s party, with the result that there are now hundreds of thousands if not millions of iatrogenic — that is to say, medically created — addicts.

An editorial in the New England Journal of Medicine asks why this change happened, and provides at least two possible answers.

The first is that there has been a sea change in medical and social sensibility. Nowadays, doctors feel constrained to take patients at their word: a patient is in pain if he says he is because he is supposedly the best authority on his own state of mind and the sensations that he feels. This certainly meant that at the hospital where I worked you could see patients, allegedly with severe and incapacitating back pain, skipping up the stairs and returning with their prescriptions for the strongest analgesics to treat their supposed pain. In the new dispensation, doctors were professionally bound to believe what the patients said, not what they observed them doing.

The automatic credence placed in what a patient says — or credulity, if you prefer — is deemed inherently more sympathetic than a certain critical or questioning attitude towards it. And since it is now possible, indeed normal, for patients to report on doctors adversely and very publicly via the internet and other electronic media, doctors find themselves in a situation in which they must do what patients want or have their reputations publicly ruined. When in doubt, then, prescribe.

The second reason proposed in the editorial for the liberal prescription of addictive analgesics, even to those patients whom the doctor knows or suspects to be abusing them, is economic. Prescription is quick and lucrative, while encouraging the patient to forego his drugs is difficult, time-consuming, and ill-paid. The doctor cannot afford, at least if he wants to preserve his income, to spend a lot of time with any one patient, and addicts denied their drugs can easily use up hours of the doctor’s time.

Practically all doctors (apart from pathologists) must now take courses in pain management, but not in the addiction to which the proliferation of these courses seem to have led. The author of the editorial, who is from Stanford, believes that not until doctors accept addiction as a disease, chronic and relapsing like, say, asthma, and are duly rewarded for treating it, will the problem be solved. The trouble is that addiction is not a disease like any other, any more than is burglary or driving too fast. Medical consequences do not make a disease.

Nevertheless, the editorial draws attention to the pressures on doctors to prescribe what they know in their hearts they ought not to prescribe. It omits, however, three factors: the unprecedented commercial promotion of strong painkillers by drug companies, the doctor’s physical fear of his patient

s (assaults by the disgruntled are not uncommon), and a strong dislike of scenes in his office. I remember very well that when I refused to prescribe either strong painkillers or other addictive drugs such as benzodiazepines (for example, valium), some of the patients would start to shout that I was not a doctor but a murderer. This was idiotic, of course, but such scenes are wearing on the nerves. Many doctors just give in prophylactically, as it were.

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All Comments   (9)
All Comments   (9)
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More than half of these questions would simply go away if everyone (or their family or close friends as needed) paid for their own health care. For the remainder - perhaps excerpting parental responsibility for an obese child - it is sufficient for everyone to have their own opinion and act accordingly.
36 weeks ago
36 weeks ago Link To Comment
There's so much PC BS on most topics that it's startling to hear or read TS, "true speak." Thanks, Doc.
36 weeks ago
36 weeks ago Link To Comment
RE: Obesity & RE:Healthy Diet. I know 17 people with Hypo-Throidism, & most continue to gain weight eating healthy low cal diets with lots of aerobic exercise. I doubt most overweight people have this, but some do have a medical reason for obesity, likely a small minority. Those who simply choose a poor diet likely fall into one of these categories...1) I will eat what I want (needs immediate & constant gratification). 2) Too uninformed (or ill informed) to make intelligent choices. 3) Too poor to buy healthy food (the price, per calorie, of junk food has dropped, while the cost of real food has skyrocketed). If most people would eliminate all processed foods made with white flour & white sugar, & replace that with a MUCH SMALLER amount of whole grains than the food pyramid recommends & eat mostly lean sources of protein + lots of organic produce, they would naturally loose weight. For weight loss to be permanent, you have to make permanent changes!! "Let thy food be medicine & let thy medicine be food"...Hippocrates
36 weeks ago
36 weeks ago Link To Comment
Here in NV our absurd Medical Marijuana laws require a patient to break the law BEFORE they can comply with it. First, you have to break the law & illegally obtain the seeds. Then you apply for a Medical Marijuana card ($50.00), then pay another $50.00 for an "Illegal Contraband Tax Stamp", (no I'm NOT making that up). Then you have to "grow your own". Once "your crop comes in"...you FINALLY have your medicine. As a patient who laid in bed CRYING AND SCREAMING IN AGONIZING PAIN FOR MONTHS ON END, because pain pills don't work on me, NOT opiates & NOT NSAIDS, I can tell you that "witch hunt" leveled against Medical Marijuana is merely "cover" to TORTURE cancer patients like me. I choose not to break the law, because there's no telling when/who the Fed. Gov't. will turn on next & my Hubby is a legal immigrant, here on a Green Card from Canada...so I SUFFERED!! The freely available (by RX) dangerous, highly addictive, toxic narcotics & their horrific side-effects they "experimented on me with" are what we should be worried about...NOT a plant that grows out of the ground!!
36 weeks ago
36 weeks ago Link To Comment
With the understanding that people should be free to obtain help for obesity, addiction, and all health issues at any age, but cannot demand that others pay for this treatment (Charity given by others is ok and encouraged), my take is as follows. Let the debate begin.

1. Obesity is neither a disease nor a moral failing
2. Alcoholics should not be denied available medical care
3. Psychiatric illnesses merit treatment as much as physical illnesses
4. Doctors sometimes are guilty of giving pain killers to addicts who con them
5. Elderly should not be denied available medical care
6. Marijuana can be a medicine, with side effects
7. Nutrition is important to health
8. Drug addiction is not like non-addiction illnesses but addicts should be treated
9. Obese children are not victims of child abuse
10. Parents should vaccinate their children
36 weeks ago
36 weeks ago Link To Comment
Interesting that the author chose only one vaccine to discuss pros and cons.
36 weeks ago
36 weeks ago Link To Comment
He must be in on the CONSPIRACY!!!!!!!
36 weeks ago
36 weeks ago Link To Comment
A government funded psychiatrist on an NHS pension in on 'the conspiracy'? No. Not possible.
36 weeks ago
36 weeks ago Link To Comment
Thank you, Doctor, for this thoughtful and objective article. These are two qualities that in tandem are virtuous but rarely encountered today.
36 weeks ago
36 weeks ago Link To Comment
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