Philosophy Discussion Forums | A Humans-Only Club for Open-Minded Discussion & Debate

[Sushan]

As to the communication, I personally find it inconceivable that there is a smoker (or alcoholic, or overeater etc) who is unaware of the fact that smoking is bad for them and that they should quit. Thus, for me personally, I don't browbeat folks with unsolicited advice and information they already know. OTOH, if someone reaches out and asks "can you help me quit smoking?", I'll talk their ear off. In my experience there is NO positive effect of not being on your patient's side, thus I'm never in an opposing position to my patients.

Good! However can you help an addict to understand if and when they are rationalising the bad choice ? I who have quite a large vocabulary don't know a popular synonym for 'rationalising'. I wonder if there is one. I hope so.

In my experience, folks use "rationalizations" when they are feeling defensive, that is they feel they are being judged. Since I: 1) only get involved when invited and 2) focus on meeting the patient's goal, as opposed to how they got to their current state (since they know that already and resent harping on it), I don't actually deal with any rationalizations.

While this approach minimizes encounters with rationalizations by not placing individuals in defensive positions, I wonder about situations where understanding or addressing rationalizations might still be beneficial.

For instance, in scenarios where individuals themselves bring up rationalizations as barriers to their progress, or when they're struggling to recognize these thought patterns independently. Perhaps, in these cases, guiding individuals to identify and work through their rationalizations, in a supportive and non-judgmental manner, could further empower them in their journey towards recovery.

In your experience, have there been moments where addressing rationalizations, directly or indirectly, contributed to a breakthrough in the patient's journey? And how might we, as supporters, better equip ourselves to navigate these nuanced interactions?

[LuckyR]

And so I answer the question from the OP : if we retain the ethic to save a life , any life, when reasonably possible then health care is necessary. Pragmatically, health care is necessary if we are to save the lives of the next generation, and also productive adults. Psychologically, health care is necessary unless we decide it's okay to brutalise ourselves or others.

Well, I think most of the citizenry agree with "healthcare" being a necessary "right" for all. But to draw an analogy, if transportation is also a "right" that means reasonable bus fare, not everyone gets a Ferrari. Healthcare is also stratified in terms of cost and utility. So the main disagreement isn't necessity or not, it's what if the homeless guy needs a liver transplant? What if his liver damage is because of alcohol use? And are you OK with your taxes going up (and your non medical services going down) to pay for it?

[Sushan]

In my experience, folks use "rationalizations" when they are feeling defensive, that is they feel they are being judged. Since I: 1) only get involved when invited and 2) focus on meeting the patient's goal, as opposed to how they got to their current state (since they know that already and resent harping on it), I don't actually deal with any rationalizations.

Advertisers well know how to insert rationalisations into minds. There was an advertisement for milk chocolate with the caption "Go on ! You know you deserve it." And there is the plethora of image making that dwells on valiant cowboys and sailors, or aristocratic lifestyle and appearance, or sexual attractiveness, or benign father figure, or pseudoscience .I believe I have seen all of those images in cigarette advertising. I keep banging on about education being the answer to all sorts of problems, and education from primary school level onwards on how to be sceptical would vastly aid the medic in their work, who is trying to help patients ; although maybe not with severe physical addiction to such substances as opiates.

I agree such advertising helps young non-smokers take it up, though IMO if nicotine instead of being the most addictive substance known, was not physically addictive, quitting smoking would be much, much easier and the number of cigarette smokers would be a tiny fraction of what it is currently. Counterintuitively, the number of cigar, pipe and chewing tobacco users would likely be similar.

It's interesting to consider the role of physical addictiveness in the prevalence of smoking, as you've outlined with nicotine being a major factor. This perspective sheds light on why quitting smoking is so challenging for many and how it influences the number of cigarette smokers. However, your point also prompts me to think about the broader spectrum of addictive behaviors, particularly those that might not be as strongly associated with physical dependency.

For instance, consider the example of eating chocolate, which many people find themselves 'addicted' to. While the physical addictiveness of chocolate might be considerably less intense compared to nicotine, the cravings and habitual consumption patterns can still be quite strong. This raises questions about the psychological and emotional factors contributing to addiction.

How would you explain the phenomenon of chocolate addiction within your concept? It seems that if physical addictiveness alone were the determinant, then chocolate would not be as compelling. Yet, many find it difficult to moderate their consumption, suggesting that other factors are at play. Does this imply that the psychological component of addiction is as significant, if not more so, in certain cases than the physical aspect? And how might this understanding influence our approach to addressing different forms of addiction?

[Sushan]

In my experience, folks use "rationalizations" when they are feeling defensive, that is they feel they are being judged. Since I: 1) only get involved when invited and 2) focus on meeting the patient's goal, as opposed to how they got to their current state (since they know that already and resent harping on it), I don't actually deal with any rationalizations.

Advertisers well know how to insert rationalisations into minds. There was an advertisement for milk chocolate with the caption "Go on ! You know you deserve it." And there is the plethora of image making that dwells on valiant cowboys and sailors, or aristocratic lifestyle and appearance, or sexual attractiveness, or benign father figure, or pseudoscience .I believe I have seen all of those images in cigarette advertising. I keep banging on about education being the answer to all sorts of problems, and education from primary school level onwards on how to be sceptical would vastly aid the medic in their work, who is trying to help patients ; although maybe not with severe physical addiction to such substances as opiates.

I agree such advertising helps young non-smokers take it up, though IMO if nicotine instead of being the most addictive substance known, was not physically addictive, quitting smoking would be much, much easier and the number of cigarette smokers would be a tiny fraction of what it is currently. Counterintuitively, the number of cigar, pipe and chewing tobacco users would likely be similar.

Good! However can you help an addict to understand if and when they are rationalising the bad choice ? I who have quite a large vocabulary don't know a popular synonym for 'rationalising'. I wonder if there is one. I hope so.

In my experience, folks use "rationalizations" when they are feeling defensive, that is they feel they are being judged. Since I: 1) only get involved when invited and 2) focus on meeting the patient's goal, as opposed to how they got to their current state (since they know that already and resent harping on it), I don't actually deal with any rationalizations.

Advertisers well know how to insert rationalisations into minds. There was an advertisement for milk chocolate with the caption "Go on ! You know you deserve it." And there is the plethora of image making that dwells on valiant cowboys and sailors, or aristocratic lifestyle and appearance, or sexual attractiveness, or benign father figure, or pseudoscience .I believe I have seen all of those images in cigarette advertising. I keep banging on about education being the answer to all sorts of problems, and education from primary school level onwards on how to be sceptical would vastly aid the medic in their work, who is trying to help patients ; although maybe not with severe physical addiction to such substances as opiates.

I remain puzzled. Is physical addiction always or sometimes a matter of all or nothing(kind) or are there degrees of physiological addiction and if so do these depend on the patient's personality and other variables?
Is behavioral addiction a thing like a broken leg is a thing , or is it an analogy with physiological addiction?
I imagine addiction is not a thing but is a useful heuristic device the parameters of which are set by mutual consent of clinicians and the compliance of patients and others. For instance if a woman walks into a Alcoholics Anonymous meeting and announces " I am Jane and I am an alcoholic" she is compliant with the normal heuristic.

Your questions touch on some critical nuances in the understanding of addiction. Firstly, physiological (or physical) addiction and behavioral addiction are indeed recognized differently, but both are complex and multifaceted, rather than all-or-nothing phenomena.

Physiological addiction refers to the body's dependence on a substance, characterized by the development of tolerance (needing more of the substance to achieve the same effect) and withdrawal symptoms when the substance is not used. This type of addiction can vary in degree, influenced by the substance's nature, the frequency and duration of use, and individual biological factors.

Behavioral addiction, on the other hand, involves compulsive engagement in rewarding non-substance-related behaviors despite adverse consequences. It's recognized as a "thing" in the sense that it can significantly impair one's functioning and quality of life, much like physiological addictions. The comparison to a broken leg, however, might be less about direct analogy and more about acknowledging that behavioral addictions are real and measurable disruptions to one’s health and wellbeing, albeit through psychological mechanisms rather than physical injury.

The concept that addiction is not a "thing" but rather a "useful heuristic device" is thought-provoking. It suggests that the label of addiction is partly a social and clinical construct, designed to facilitate diagnosis and treatment. While there's truth to the social construction of addiction, it's crucial not to understate the very real biological and psychological processes involved.

The scenario of declaring oneself as an alcoholic in an AA meeting illustrates how social and personal acceptance of the addiction label can be part of the healing process. It's a form of acknowledgment and compliance with a community's norms, which fosters a supportive environment for recovery. This act doesn't just comply with a heuristic but also represents a significant step in one's acceptance and commitment to change.

[Sushan]

I remain puzzled. Is physical addiction always or sometimes a matter of all or nothing(kind) or are there degrees of physiological addiction and if so do these depend on the patient's personality and other variables?
Is behavioral addiction a thing like a broken leg is a thing , or is it an analogy with physiological addiction?
I imagine addiction is not a thing but is a useful heuristic device the parameters of which are set by mutual consent of clinicians and the compliance of patients and others. For instance if a woman walks into a Alcoholics Anonymous meeting and announces " I am Jane and I am an alcoholic" she is compliant with the normal heuristic.

I don't believe it is all worked out, but in my opinion there are pharmacoligic/neurological effects that fall under the label of physical and there are individuals who have "addictive personalities". Could there be a genetic/neurochemical etiology to the latter? Sure. Basically we all know some folks can get addicted to things (like gambling) that have zero chemical effects, that's 100% behavioral or personality based. Other chemicals like nicotine have documented profound chemical (to neurologic) effects. Could nicotine also play into certain individual's personality? Of course.

It wouldn't surprise me if it was determined that both chemical and behavioral sources have a common pathway neurologically.

Quite insightful. Let me add some more to this.

Genetic and Neurochemical Etiologies: There is substantial evidence suggesting that genetics play a significant role in the susceptibility to addiction. For example, research has identified specific genetic variants that increase the risk of developing substance use disorders. These genetic factors can affect the brain's reward systems, particularly the dopamine system, which is crucial in the experience of pleasure and reinforcement of addictive behaviors.

Addictive Personalities: The concept of an "addictive personality" is more controversial and less clearly defined in scientific literature. While it's recognized that certain personality traits (such as impulsivity, sensation-seeking, and neuroticism) are associated with a higher risk of addiction, it's also understood that addiction is not determined by personality alone. Environmental factors, such as exposure to drugs or stress, play a crucial role.

Behavioral Addictions: Regarding non-substance addictions (e.g., gambling), recent neuroimaging studies have shown that these behaviors can activate the brain's reward system in ways similar to substance use. This supports the idea that chemical and behavioral addictions may share common neurological pathways, even though the initial triggers (substance vs. behavior) differ.

Interaction Between Chemical Effects and Personality: There is evidence that the effects of substances like nicotine not only have direct neurochemical impacts but also interact with individual personality traits and predispositions. For instance, nicotine's ability to modulate mood and concentration can differentially affect individuals, potentially making it more addictive to those with certain neurobiological and psychological profiles.

[Sushan]

I remain puzzled. Is physical addiction always or sometimes a matter of all or nothing(kind) or are there degrees of physiological addiction and if so do these depend on the patient's personality and other variables?
Is behavioral addiction a thing like a broken leg is a thing , or is it an analogy with physiological addiction?
I imagine addiction is not a thing but is a useful heuristic device the parameters of which are set by mutual consent of clinicians and the compliance of patients and others. For instance if a woman walks into a Alcoholics Anonymous meeting and announces " I am Jane and I am an alcoholic" she is compliant with the normal heuristic.

I don't believe it is all worked out, but in my opinion there are pharmacoligic/neurological effects that fall under the label of physical and there are individuals who have "addictive personalities". Could there be a genetic/neurochemical etiology to the latter? Sure. Basically we all know some folks can get addicted to things (like gambling) that have zero chemical effects, that's 100% behavioral or personality based. Other chemicals like nicotine have documented profound chemical (to neurologic) effects. Could nicotine also play into certain individual's personality? Of course.

It wouldn't surprise me if it was determined that both chemical and behavioral sources have a common pathway neurologically.

That would simplify the cure for addiction. Maybe the link is the psychology and neurology of pleasure ;we all need to know how to delay satisfaction. Anger management is a case in point, I don't know how successful these anger management courses are. Then again some physiological addictions are so intensely felt that it's hard to imagine the addict surviving without chemical help from a clinician.

And so I answer the question from the OP : if we retain the ethic to save a life , any life, when reasonably possible then health care is necessary. Pragmatically, health care is necessary if we are to save the lives of the next generation, and also productive adults. Psychologically, health care is necessary unless we decide it's okay to brutalise ourselves or others.

Thank you for your insights. Your points about the ethical, pragmatic, and psychological necessities of healthcare resonate deeply with me. It's clear that healthcare is not just a service but a fundamental human need that touches on every aspect of our existence.

Ethically, the imperative to save lives whenever possible sets a profound expectation for our healthcare systems and for us as a society. It underscores the value we place on human life and the lengths we are willing to go to preserve it.

Pragmatically, the necessity of healthcare becomes evident when we consider the importance of ensuring the well-being of future generations and maintaining a productive workforce. This perspective highlights healthcare as an investment in our collective future, ensuring that society can continue to function and thrive.

Psychologically, the necessity of healthcare extends to mental and emotional well-being, reinforcing the idea that neglecting healthcare can lead to a form of societal self-harm. This aspect of healthcare is crucial for fostering a compassionate society that values the well-being of all its members.

This opens up more questions: How do we balance the innate necessity of healthcare with the challenges posed by its commercialization and our lifestyle choices? How can we ensure that healthcare systems remain focused on the well-being of individuals and society as a whole?

[Sushan]

And so I answer the question from the OP : if we retain the ethic to save a life , any life, when reasonably possible then health care is necessary. Pragmatically, health care is necessary if we are to save the lives of the next generation, and also productive adults. Psychologically, health care is necessary unless we decide it's okay to brutalise ourselves or others.

Well, I think most of the citizenry agree with "healthcare" being a necessary "right" for all. But to draw an analogy, if transportation is also a "right" that means reasonable bus fare, not everyone gets a Ferrari. Healthcare is also stratified in terms of cost and utility. So the main disagreement isn't necessity or not, it's what if the homeless guy needs a liver transplant? What if his liver damage is because of alcohol use? And are you OK with your taxes going up (and your non medical services going down) to pay for it?

Certainly, the conversation around healthcare, its accessibility, and the financial and ethical implications is vast and multifaceted. Reflecting on the points raised, it's evident that while there's a consensus on the necessity of healthcare, opinions diverge significantly when it comes to the details of implementation, funding, and prioritization.

This divergence invites a broader dialogue, one that encompasses not just the practicalities of healthcare provision but also the underlying values that should guide these decisions. Questions around fairness, responsibility, and the role of government versus personal accountability are central to this discussion.

Moreover, the mention of how we allocate resources, like in the case of providing a liver transplant to a homeless individual with a history of alcohol use, raises profound ethical considerations. It forces us to ask ourselves about the criteria we use to judge worthiness and the societal commitments we're willing to make to ensure equity in healthcare.

Engaging with these topics requires a willingness to listen, to understand diverse perspectives, and to consider the long-term implications of our choices. It's a conversation that needs the input of healthcare professionals, policymakers, and the public to navigate the complexities involved.

I'm intrigued to hear more thoughts on how we can approach these challenges in a way that balances compassion with pragmatism, ensuring that our healthcare system reflects our collective values and priorities. How do we reconcile the need for universal access with the realities of limited resources? And what steps can we take to ensure that discussions about healthcare rights and responsibilities are inclusive and equitable?

[LuckyR]

And so I answer the question from the OP : if we retain the ethic to save a life , any life, when reasonably possible then health care is necessary. Pragmatically, health care is necessary if we are to save the lives of the next generation, and also productive adults. Psychologically, health care is necessary unless we decide it's okay to brutalise ourselves or others.

Well, I think most of the citizenry agree with "healthcare" being a necessary "right" for all. But to draw an analogy, if transportation is also a "right" that means reasonable bus fare, not everyone gets a Ferrari. Healthcare is also stratified in terms of cost and utility. So the main disagreement isn't necessity or not, it's what if the homeless guy needs a liver transplant? What if his liver damage is because of alcohol use? And are you OK with your taxes going up (and your non medical services going down) to pay for it?

Certainly, the conversation around healthcare, its accessibility, and the financial and ethical implications is vast and multifaceted. Reflecting on the points raised, it's evident that while there's a consensus on the necessity of healthcare, opinions diverge significantly when it comes to the details of implementation, funding, and prioritization.

This divergence invites a broader dialogue, one that encompasses not just the practicalities of healthcare provision but also the underlying values that should guide these decisions. Questions around fairness, responsibility, and the role of government versus personal accountability are central to this discussion.

Moreover, the mention of how we allocate resources, like in the case of providing a liver transplant to a homeless individual with a history of alcohol use, raises profound ethical considerations. It forces us to ask ourselves about the criteria we use to judge worthiness and the societal commitments we're willing to make to ensure equity in healthcare.

Engaging with these topics requires a willingness to listen, to understand diverse perspectives, and to consider the long-term implications of our choices. It's a conversation that needs the input of healthcare professionals, policymakers, and the public to navigate the complexities involved.

I'm intrigued to hear more thoughts on how we can approach these challenges in a way that balances compassion with pragmatism, ensuring that our healthcare system reflects our collective values and priorities. How do we reconcile the need for universal access with the realities of limited resources? And what steps can we take to ensure that discussions about healthcare rights and responsibilities are inclusive and equitable?

Personally, I prefer the Oregon plan (which existed in the state before the Affordable Care Act). Basically that state took the total Medicaid money plus whatever the state would normally kick in, then gave every billing code a priority number (made a ranked list). Then the accountants drew a line (based on prior year's experience) such that the total money would cover the costs of the highest priority treatments and diagnostic tests for everyone without insurance BUT completely not cover those bills below the line (of lower efficacy value). Instead of the norm of covering every treatment (no matter how beneficial or not) for the extremely poor but nothing at all for say, the working poor (without insurance).

Thus using my example, liver transplants for alcoholics would be below the line ie. not paid for. Cosmetic surgery, below the line. Experimental "last ditch" cancer treatment for endstage disease, below the line. Expensive new treatments without a statistical effectiveness advantage over traditional treatment, below the line. Antibiotics for a cold, BTL.

So instead of covering any old thing for some folks and nothing for others, you'd cover the highest priority treatments for everyone.

[LuckyR]

In my experience, folks use "rationalizations" when they are feeling defensive, that is they feel they are being judged. Since I: 1) only get involved when invited and 2) focus on meeting the patient's goal, as opposed to how they got to their current state (since they know that already and resent harping on it), I don't actually deal with any rationalizations.

Advertisers well know how to insert rationalisations into minds. There was an advertisement for milk chocolate with the caption "Go on ! You know you deserve it." And there is the plethora of image making that dwells on valiant cowboys and sailors, or aristocratic lifestyle and appearance, or sexual attractiveness, or benign father figure, or pseudoscience .I believe I have seen all of those images in cigarette advertising. I keep banging on about education being the answer to all sorts of problems, and education from primary school level onwards on how to be sceptical would vastly aid the medic in their work, who is trying to help patients ; although maybe not with severe physical addiction to such substances as opiates.

I agree such advertising helps young non-smokers take it up, though IMO if nicotine instead of being the most addictive substance known, was not physically addictive, quitting smoking would be much, much easier and the number of cigarette smokers would be a tiny fraction of what it is currently. Counterintuitively, the number of cigar, pipe and chewing tobacco users would likely be similar.

It's interesting to consider the role of physical addictiveness in the prevalence of smoking, as you've outlined with nicotine being a major factor. This perspective sheds light on why quitting smoking is so challenging for many and how it influences the number of cigarette smokers. However, your point also prompts me to think about the broader spectrum of addictive behaviors, particularly those that might not be as strongly associated with physical dependency.

For instance, consider the example of eating chocolate, which many people find themselves 'addicted' to. While the physical addictiveness of chocolate might be considerably less intense compared to nicotine, the cravings and habitual consumption patterns can still be quite strong. This raises questions about the psychological and emotional factors contributing to addiction.

How would you explain the phenomenon of chocolate addiction within your concept? It seems that if physical addictiveness alone were the determinant, then chocolate would not be as compelling. Yet, many find it difficult to moderate their consumption, suggesting that other factors are at play. Does this imply that the psychological component of addiction is as significant, if not more so, in certain cases than the physical aspect? And how might this understanding influence our approach to addressing different forms of addiction?

This is not my area of expertise, but in my opinion the unspoken (thus missing) variable is the "buy in" or motivation of the individual. For example, 50% of all cigarette smokers attempt to quit in any given year, implying that there is ubiquitous knowledge of it's dangers (and thus the lack of a need to harp on them). However, despite that level of motivation, only 6% quit permanently each year. Chocolate's numbers are much closer together (much fewer than 50% try to quit, but of those who do, a higher percentage succeed). Everyone appreciates this represents the lack of physically addictive properties of chocolate compared to nicotine. But fewer note that those seeking to cut down on their chocolate intake are way, way less scared/disgusted of/by chocolate than smokers are of tobacco. Lower motivation is under-appreciated as the cause of higher failure.

[LuckyR]

Several things. First, while I agree with your assessment of the three classes of disorders you cite, they have the hallmarks of acute illness that Western medicine is designed to address. Type 1 diabetes, is the inability to produce insulin, Western medicine is great at figuring that out and figuring out how to obtain alternative insulin and delivering it (which it did). Cancer (when treatable) is currently a classic, acute style Western medicine success story, cut it out, radiate it or poison it with chemo. Now the scientific breakthrough of biologicals continues along that model. Similarly, autoimmune disorders have been reduced to: "block this protein" with the advent of antibody drugs, which is classic acute illness strategy that Western medicine is designed to tackle.

As to avoiding sounding like one is blaming, it's not difficult if one waits until the patient demonstrates interest/motivation, then using the solution to the problem as the focus (rather than the source of the problem).

I find myself a bit perplexed by the demarcation you're making between acute and chronic conditions, particularly with your reference to Type 1 Diabetes (T1D) as an example of an acute illness. Could you clarify this distinction further for a more productive discussion?

T1D is widely recognized in medical practice as a chronic illness, not an acute one. Chronic illnesses are defined by their long duration and generally slow progression, whereas acute illnesses are characterized by their sudden onset and typically short duration. T1D involves a lifelong management of blood sugar levels due to the body's inability to produce insulin, which doesn't align with the characteristics of acute illnesses.

Your categorizations and definitions have left me a bit confused.

T1D is currently a chronic illness because insulin treatment is available, just like AIDS is currently a chronic disease because antiviral medications exist. However, before insulin treatment was discovered half of diabetics died within 2 years of diagnosis. Nope, it was definitely an acute illness. You may not remember when AIDS splashed onto the scene in the 80s, it made the Covid pandemic stress seem trivial. Folks were (rightly) freaked out by the acute illness that was AIDS, people understand that but perhaps haven't stopped to reassess that currently (especially among the young) HIV is viewed as a chronic illness that is "managed" with pills or an occasional injection.

Thus the very chronicity of T1D (currently) is specifically because of Western medicine's turning it so because of it's efficiency against the acute illness that T1D started out as.

[Sushan]

And so I answer the question from the OP : if we retain the ethic to save a life , any life, when reasonably possible then health care is necessary. Pragmatically, health care is necessary if we are to save the lives of the next generation, and also productive adults. Psychologically, health care is necessary unless we decide it's okay to brutalise ourselves or others.

Well, I think most of the citizenry agree with "healthcare" being a necessary "right" for all. But to draw an analogy, if transportation is also a "right" that means reasonable bus fare, not everyone gets a Ferrari. Healthcare is also stratified in terms of cost and utility. So the main disagreement isn't necessity or not, it's what if the homeless guy needs a liver transplant? What if his liver damage is because of alcohol use? And are you OK with your taxes going up (and your non medical services going down) to pay for it?

Certainly, the conversation around healthcare, its accessibility, and the financial and ethical implications is vast and multifaceted. Reflecting on the points raised, it's evident that while there's a consensus on the necessity of healthcare, opinions diverge significantly when it comes to the details of implementation, funding, and prioritization.

This divergence invites a broader dialogue, one that encompasses not just the practicalities of healthcare provision but also the underlying values that should guide these decisions. Questions around fairness, responsibility, and the role of government versus personal accountability are central to this discussion.

Moreover, the mention of how we allocate resources, like in the case of providing a liver transplant to a homeless individual with a history of alcohol use, raises profound ethical considerations. It forces us to ask ourselves about the criteria we use to judge worthiness and the societal commitments we're willing to make to ensure equity in healthcare.

Engaging with these topics requires a willingness to listen, to understand diverse perspectives, and to consider the long-term implications of our choices. It's a conversation that needs the input of healthcare professionals, policymakers, and the public to navigate the complexities involved.

I'm intrigued to hear more thoughts on how we can approach these challenges in a way that balances compassion with pragmatism, ensuring that our healthcare system reflects our collective values and priorities. How do we reconcile the need for universal access with the realities of limited resources? And what steps can we take to ensure that discussions about healthcare rights and responsibilities are inclusive and equitable?

Personally, I prefer the Oregon plan (which existed in the state before the Affordable Care Act). Basically that state took the total Medicaid money plus whatever the state would normally kick in, then gave every billing code a priority number (made a ranked list). Then the accountants drew a line (based on prior year's experience) such that the total money would cover the costs of the highest priority treatments and diagnostic tests for everyone without insurance BUT completely not cover those bills below the line (of lower efficacy value). Instead of the norm of covering every treatment (no matter how beneficial or not) for the extremely poor but nothing at all for say, the working poor (without insurance).

Thus using my example, liver transplants for alcoholics would be below the line ie. not paid for. Cosmetic surgery, below the line. Experimental "last ditch" cancer treatment for endstage disease, below the line. Expensive new treatments without a statistical effectiveness advantage over traditional treatment, below the line. Antibiotics for a cold, BTL.

So instead of covering any old thing for some folks and nothing for others, you'd cover the highest priority treatments for everyone.

Thank you for sharing information about the Oregon plan, which presents a unique approach to managing healthcare resources. It's enlightening to learn about systems that aim to allocate medical funding in a way that maximizes efficacy and fairness across the board. The strategy of ranking treatments by priority and drawing a financial line to determine what gets funded is an intriguing model that strives for efficiency and equity in healthcare provision. I appreciate the thoughtfulness behind such a system, as it attempts to ensure that the most crucial treatments are accessible to everyone, rather than providing comprehensive coverage to a few while leaving others without any support.

However, the ethical implications of this system, particularly regarding treatments that fall below the line, such as liver transplants for alcoholics or experimental cancer treatments, raise significant concerns. It's a challenging ethical dilemma: on one hand, the system seeks to use limited resources wisely, focusing on treatments with the highest efficacy and benefit. On the other hand, it inevitably leads to tough decisions about who gets treatment and who doesn't, which can feel like a judgment on the value of certain lives or conditions.

The example of denying liver transplants for alcoholics or withholding experimental treatments for end-stage cancer patients highlights a critical ethical question: How do we reconcile the need to allocate resources efficiently with the moral imperative to treat all individuals with compassion and dignity, regardless of their circumstances?

I'm curious about your perspective on this ethical dimension. How do you view the balance between efficiency and fairness in this system, especially when it comes to decisions that could mean life or death for individuals whose treatments fall below the line? Is there a way to address these ethical concerns within the framework of such a prioritized funding system, or are there alternative approaches that might better navigate these complex moral waters?

[Sushan]

Advertisers well know how to insert rationalisations into minds. There was an advertisement for milk chocolate with the caption "Go on ! You know you deserve it." And there is the plethora of image making that dwells on valiant cowboys and sailors, or aristocratic lifestyle and appearance, or sexual attractiveness, or benign father figure, or pseudoscience .I believe I have seen all of those images in cigarette advertising. I keep banging on about education being the answer to all sorts of problems, and education from primary school level onwards on how to be sceptical would vastly aid the medic in their work, who is trying to help patients ; although maybe not with severe physical addiction to such substances as opiates.

I agree such advertising helps young non-smokers take it up, though IMO if nicotine instead of being the most addictive substance known, was not physically addictive, quitting smoking would be much, much easier and the number of cigarette smokers would be a tiny fraction of what it is currently. Counterintuitively, the number of cigar, pipe and chewing tobacco users would likely be similar.

It's interesting to consider the role of physical addictiveness in the prevalence of smoking, as you've outlined with nicotine being a major factor. This perspective sheds light on why quitting smoking is so challenging for many and how it influences the number of cigarette smokers. However, your point also prompts me to think about the broader spectrum of addictive behaviors, particularly those that might not be as strongly associated with physical dependency.

For instance, consider the example of eating chocolate, which many people find themselves 'addicted' to. While the physical addictiveness of chocolate might be considerably less intense compared to nicotine, the cravings and habitual consumption patterns can still be quite strong. This raises questions about the psychological and emotional factors contributing to addiction.

How would you explain the phenomenon of chocolate addiction within your concept? It seems that if physical addictiveness alone were the determinant, then chocolate would not be as compelling. Yet, many find it difficult to moderate their consumption, suggesting that other factors are at play. Does this imply that the psychological component of addiction is as significant, if not more so, in certain cases than the physical aspect? And how might this understanding influence our approach to addressing different forms of addiction?

This is not my area of expertise, but in my opinion the unspoken (thus missing) variable is the "buy in" or motivation of the individual. For example, 50% of all cigarette smokers attempt to quit in any given year, implying that there is ubiquitous knowledge of it's dangers (and thus the lack of a need to harp on them). However, despite that level of motivation, only 6% quit permanently each year. Chocolate's numbers are much closer together (much fewer than 50% try to quit, but of those who do, a higher percentage succeed). Everyone appreciates this represents the lack of physically addictive properties of chocolate compared to nicotine. But fewer note that those seeking to cut down on their chocolate intake are way, way less scared/disgusted of/by chocolate than smokers are of tobacco. Lower motivation is under-appreciated as the cause of higher failure.

Your observations about the role of individual motivation in quitting addictive behaviors, such as smoking, and habits like excessive chocolate consumption, provide a valuable perspective. Indeed, approximately 50% of smokers attempt to quit each year, highlighting widespread awareness of smoking's dangers. Yet, with only a 6% success rate for quitting smoking permanently annually, it's evident that despite high motivation, overcoming nicotine addiction is exceptionally challenging. This contrast with chocolate, where a smaller percentage of individuals attempt to quit, but a higher success rate among those who do, underscores the significant impact of nicotine's addictive properties compared to the psychological and emotional ties to chocolate.

The difference in motivation levels and perceived risks between quitting smoking and reducing chocolate intake is striking. Smokers often face the stark reality of smoking's health risks, which can significantly boost their motivation to quit, despite the low success rate attributed to nicotine's strong addictive qualities. On the other hand, chocolate, lacking such physically addictive properties, doesn't evoke the same level of fear or disgust, leading to lower motivation levels among individuals trying to cut down on it. This scenario illustrates the complex interplay between physical addiction, psychological factors, and the role of motivation in changing behavior. It emphasizes the importance of understanding both the substance-specific challenges and the individual's psychological state in addressing addictive behaviors and habits effectively.

Considering the complexity of these factors, it's worth exploring further how interventions can be tailored to address both the physical and psychological aspects of addiction. For instance, how can healthcare providers and support systems better leverage the understanding of motivation in their approaches? And what additional factors should be considered when designing support mechanisms for individuals trying to quit smoking or reduce their intake of foods like chocolate?

[Sushan]

Several things. First, while I agree with your assessment of the three classes of disorders you cite, they have the hallmarks of acute illness that Western medicine is designed to address. Type 1 diabetes, is the inability to produce insulin, Western medicine is great at figuring that out and figuring out how to obtain alternative insulin and delivering it (which it did). Cancer (when treatable) is currently a classic, acute style Western medicine success story, cut it out, radiate it or poison it with chemo. Now the scientific breakthrough of biologicals continues along that model. Similarly, autoimmune disorders have been reduced to: "block this protein" with the advent of antibody drugs, which is classic acute illness strategy that Western medicine is designed to tackle.

As to avoiding sounding like one is blaming, it's not difficult if one waits until the patient demonstrates interest/motivation, then using the solution to the problem as the focus (rather than the source of the problem).

I find myself a bit perplexed by the demarcation you're making between acute and chronic conditions, particularly with your reference to Type 1 Diabetes (T1D) as an example of an acute illness. Could you clarify this distinction further for a more productive discussion?

T1D is widely recognized in medical practice as a chronic illness, not an acute one. Chronic illnesses are defined by their long duration and generally slow progression, whereas acute illnesses are characterized by their sudden onset and typically short duration. T1D involves a lifelong management of blood sugar levels due to the body's inability to produce insulin, which doesn't align with the characteristics of acute illnesses.

Your categorizations and definitions have left me a bit confused.

T1D is currently a chronic illness because insulin treatment is available, just like AIDS is currently a chronic disease because antiviral medications exist. However, before insulin treatment was discovered half of diabetics died within 2 years of diagnosis. Nope, it was definitely an acute illness. You may not remember when AIDS splashed onto the scene in the 80s, it made the Covid pandemic stress seem trivial. Folks were (rightly) freaked out by the acute illness that was AIDS, people understand that but perhaps haven't stopped to reassess that currently (especially among the young) HIV is viewed as a chronic illness that is "managed" with pills or an occasional injection.

Thus the very chronicity of T1D (currently) is specifically because of Western medicine's turning it so because of it's efficiency against the acute illness that T1D started out as.

The World Health Organization (WHO) provides clear definitions to distinguish between acute and chronic illnesses, which can help clarify the discussion:

- Acute Illness: An acute condition is typically characterized by a sudden onset and is usually of short duration. Acute illnesses can range in severity from mild conditions requiring minimal intervention to severe, life-threatening emergencies. The key aspect of an acute illness is its transient nature.

- Chronic Illness: Chronic conditions, on the other hand, are long-developing syndromes, defined by WHO as requiring “long-term management over a period of years or decades”. They are often characterized by their persistent and prolonging effects on the individual's health, requiring ongoing medical attention or limit activities of daily living or both.

Based on your comment, it seems there might be a misunderstanding or a conflation of the terms "acute" and "chronic" based on the availability of treatment and the historical fatality rates of conditions like T1D and AIDS. It's important to note that the classification of an illness as acute or chronic typically does not hinge solely on whether it leads to quick death without treatment. Rather, it's about the duration and course of the disease - whether it's of short duration (acute) or persists for a long time, often for the person's lifetime (chronic), and requires long-term management.

However, I'm curious about your statement implying that an illness is considered "acute" only if it leads to a quick death in the absence of treatment. Could you clarify if this is your stance?

[LuckyR]

Personally, I prefer the Oregon plan (which existed in the state before the Affordable Care Act). Basically that state took the total Medicaid money plus whatever the state would normally kick in, then gave every billing code a priority number (made a ranked list). Then the accountants drew a line (based on prior year's experience) such that the total money would cover the costs of the highest priority treatments and diagnostic tests for everyone without insurance BUT completely not cover those bills below the line (of lower efficacy value). Instead of the norm of covering every treatment (no matter how beneficial or not) for the extremely poor but nothing at all for say, the working poor (without insurance).

Thus using my example, liver transplants for alcoholics would be below the line ie. not paid for. Cosmetic surgery, below the line. Experimental "last ditch" cancer treatment for endstage disease, below the line. Expensive new treatments without a statistical effectiveness advantage over traditional treatment, below the line. Antibiotics for a cold, BTL.

So instead of covering any old thing for some folks and nothing for others, you'd cover the highest priority treatments for everyone.

Thank you for sharing information about the Oregon plan, which presents a unique approach to managing healthcare resources. It's enlightening to learn about systems that aim to allocate medical funding in a way that maximizes efficacy and fairness across the board. The strategy of ranking treatments by priority and drawing a financial line to determine what gets funded is an intriguing model that strives for efficiency and equity in healthcare provision. I appreciate the thoughtfulness behind such a system, as it attempts to ensure that the most crucial treatments are accessible to everyone, rather than providing comprehensive coverage to a few while leaving others without any support.

However, the ethical implications of this system, particularly regarding treatments that fall below the line, such as liver transplants for alcoholics or experimental cancer treatments, raise significant concerns. It's a challenging ethical dilemma: on one hand, the system seeks to use limited resources wisely, focusing on treatments with the highest efficacy and benefit. On the other hand, it inevitably leads to tough decisions about who gets treatment and who doesn't, which can feel like a judgment on the value of certain lives or conditions.

The example of denying liver transplants for alcoholics or withholding experimental treatments for end-stage cancer patients highlights a critical ethical question: How do we reconcile the need to allocate resources efficiently with the moral imperative to treat all individuals with compassion and dignity, regardless of their circumstances?

I'm curious about your perspective on this ethical dimension. How do you view the balance between efficiency and fairness in this system, especially when it comes to decisions that could mean life or death for individuals whose treatments fall below the line? Is there a way to address these ethical concerns within the framework of such a prioritized funding system, or are there alternative approaches that might better navigate these complex moral waters?

Well, typically the standard criticism of the Oregon plan is: "that's Healthcare rationing, I'm against that". However, anyone with a more in depth understanding of the topic realizes that the standard system also rations Healthcare, but instead of limiting the least efficacious treatments, it completely excludes whole sections of the population. Better IMO to exclude procedures than people.

[LuckyR]

T1D is currently a chronic illness because insulin treatment is available, just like AIDS is currently a chronic disease because antiviral medications exist. However, before insulin treatment was discovered half of diabetics died within 2 years of diagnosis. Nope, it was definitely an acute illness. You may not remember when AIDS splashed onto the scene in the 80s, it made the Covid pandemic stress seem trivial. Folks were (rightly) freaked out by the acute illness that was AIDS, people understand that but perhaps haven't stopped to reassess that currently (especially among the young) HIV is viewed as a chronic illness that is "managed" with pills or an occasional injection.

Thus the very chronicity of T1D (currently) is specifically because of Western medicine's turning it so because of it's efficiency against the acute illness that T1D started out as.

The World Health Organization (WHO) provides clear definitions to distinguish between acute and chronic illnesses, which can help clarify the discussion:

- Acute Illness: An acute condition is typically characterized by a sudden onset and is usually of short duration. Acute illnesses can range in severity from mild conditions requiring minimal intervention to severe, life-threatening emergencies. The key aspect of an acute illness is its transient nature.

- Chronic Illness: Chronic conditions, on the other hand, are long-developing syndromes, defined by WHO as requiring “long-term management over a period of years or decades”. They are often characterized by their persistent and prolonging effects on the individual's health, requiring ongoing medical attention or limit activities of daily living or both.

Based on your comment, it seems there might be a misunderstanding or a conflation of the terms "acute" and "chronic" based on the availability of treatment and the historical fatality rates of conditions like T1D and AIDS. It's important to note that the classification of an illness as acute or chronic typically does not hinge solely on whether it leads to quick death without treatment. Rather, it's about the duration and course of the disease - whether it's of short duration (acute) or persists for a long time, often for the person's lifetime (chronic), and requires long-term management.

However, I'm curious about your statement implying that an illness is considered "acute" only if it leads to a quick death in the absence of treatment. Could you clarify if this is your stance?

Considered by administrators? (who are those who sit in meetings at conferences to form committees to come up with definitions) As a clinician and a non administrator, I'm not an expert in the various lumping and splitting of diagnosis coding into semi arbitrary categories. Of course you're likely not one either.

But I'm sure at this point you understand the significant difference between being told your kid has a lethal diagnosis such that there's a 50% chance of dying in the next 2 years as opposed to your kid has a completely manageable lifelong illness that will require numerous, numerous clinic visits where we will do lifelong testing and use those results to adjust their treatment so that we avoid some serious long-term risks that may be significant in their elder years.

I happen to use the term "acute" to describe the former and "chronic" to describe the latter. However I'm not personally too impressed with labels except as a shortcut for communication. Since I've communicated this difference, my interest at this point in their label is miniscule.