heorhcore

volume 1, issue 2 november, 2001

What's It Really like?
Two Middle-Eastern physicians talk about life
after September 11
Synthetic Competency
and Execution
A real ethical dilemma.
War, Passion, and Payback
Where the theoretical world of pacifism meets
the real world of retribution.
When You Hear Hoofbeats
California's Department of Managed
Care Whacks Providers
Are We Hysterical?
Private Public Health Infrastructure
ETYA Insurance
Book Review: Oxymorons
A Real Reader Response
The Real Back Page
Dear Ms. Abercrombie:
How disappointing it is to read of your
support for a state sponsored anti-smoker
campaign. (Real Healthcare, September 2001).
This campaign, like most modem
American moral crusades, is claimed to be
hygienically essential. It is said to be med-
ically necessary to protect people from them-
selves: smokers engage in a risky habit and
they should be discouraged or prevented
from continuing.
Is engaging in risky, even highly risky,
behavior immoral or unethical? Why?
Because one might be harmed or killed? Are
race car drivers and sky divers as "very uneth-
ical" and people who live by a programmatic
regime of healthy eating, moderate exercise,
driving SUVs, and avoiding daring activities
are rated "highly moral, decent citizens"?
Or perhaps engaging in the behavior is
value-free while producing the product
which enables the behavior is evil. If that is
the case, then let us return to the days of
home stills and rolling papers so you won't
have anymore evil tobacco and liquor com-
panies to disturb your sleep. Long-term
smokers engage in one of the most risky
behaviors. If smoking didn't exist, something
else would top the risk list. Since reducing
risky behavior is the goal then we would
have to target -scapegoat- the people who
engage in the riskiest behaviors at the time.
We would never run out of scapegoats.
I suggest to you that government has no
business scapegoating anyone who is not
engaged in criminal behavior, and the defini-
tion of such behavior should be limited to those
who directly and immediately harm others.
Because Americans prefer to fudge moral
issues, it is more popular to attack cigarette
companies than smokers. Smokers are scape-
goated, to be sure, but not to the extent that
the manufacturers are. We do the same with
illicit drugs, abortion, and prostitution. The
penalties are far greater for selling cocaine
than using it, for selling sex than for buying
it. Even Rev. Fallwell doesn't advocate put-
ting women who obtain abortions in jail if
the procedure is made again illegal. He wants
to jail the physicians, clinic and hospital
staff. I don't think any of these activities
should be illegal, except as may relate to
minors.
It is acceptable to anti-smokers that the
government spends money on this scapegoat-
ing crusade, but how does it get that money?
The cigarette companies obtain the riches
to which you object by selling a product to
'
people who voluntarily purchase it. The state A Provocative
obtains its anti-smoking funds by coercing
unwilling individuals to pay. If they refuse to R f
pay, engaging in civil disobedience, they will esponse rom
be imprisoned or worse, depending on their
level of defense of their money. So, the ethi- a Real Reader
cal position you advocate is one in which it
is acceptable to target and bring government
force against persons whose behavior you
dislike, using their own money to persecute
them. This is done in the name of health, of
course, as if health were the only value that
people cherish and you and your allies knew
what was best for the rest of us.
When we have stamped out smoking (or
driven it underground), we can turn our
attention to fat people, sexually adventurous
people, those who allow their kids to ride go-
karts ... there is no end to this list.
In reality, the targets for scapegoating are
not chosen rationally, any more than it was
rational for the Nazis to target jews. The
scapegoats are chosen based on their status
as social outcasts, not based on a scientific
litmus. "Nice People" ingest mood changers
prescribed by physicians and become First
Lady, "Not Nice People" ingest mood chang-
ers produced in Colombia and go to jail. We
ostracize smokers but we celebrate race car
drivers. At least that is the way it is now. It
can be foreseen that you will write a cheerful
editorial attacking car makers for producing
fast cars that maim and kill.
just about the riskiest contemporary
behavior I can think of has been homosexual
promiscuity. Do you advocate billboards,
brochures, and radio spots that target urban
homosexuals as a scourge to be eradicated?
Why, in the world of state-imposed
healthiness, should anyone be allowed to
have sex with another person who is not first
tested as disease-free? Does the fact that sex
is a personal and consensual behavior offer
adequate justification?
Anti-smoking campaigns are a massive
invasion of the private lives of smokers. It
doesn't seem sufficient to reply, "It's none of
your business," because you have decided
that whatever is healthy is your business. Yet,
are you willing to allow the state and others
to hunt through your private life for risky
behaviors in which you may now or previ-
ously engaged? California may want to know
if you now or have ever had sex with a per-
son whose sexual history is/was unknown.
California may want to know if you use con-
doms, and if they are brands carefully select-
ed for efficacy. Some wonder why you
Nicholas Martin
Our Response:
Mr. Martin, yours is a courageous, well-
written, and well-argued point of view.
We're printing it for that reason. It Is not,
however, particularly relevant to my arl'icle.
I do admire your zesty enthusiasm, though.
My article was about the fight between the
State of California and tobacco companies,
not an assertion that the State is correct.
It's amusing that California is as hard-core
in its campaign as the tobacco companies
are in theirs. Both entities are on solid
ground as far as I am concerned.
No company is obligated to be socially
responsible. It is consumers who determine
the ultimate appropriateness of a product.
At the same time, the State has the right
to attempt to protect its citizens against a
health hazard. Saying, "you shouldn't
smoke because it gives you cancer," is a lot
like saying, "eat five servings of vegetables
a day to ward off cancer." The State would
be wrong to try to ban smoking, but telling
citizens that It is a dangerous thing is fair.
It is absurd that a tobacco company is
telling tell us, "We care about your health,"
because they don't. If they did they would
be in a different business. They aren't bad
because they don't care -it isn't their job
to care- but they shouldn't say that they
do when they don't. They want to make
money and survive, just like any other
company.
That's just capitalism. I'm all for ferocious
markel'ing. I just wish they'd market me
by saying "here's our cigarette ... it tastes
good, makes you feel good, and makes
you look cool to idiots," instead of" buy
our cigarettes because we care about
your health." Do I look like a stooge or
something?
I think that my words can stand proudly
next to Ben Franklin's quote. The fact that
cigarette companies exist in spite oftfle dan-
ger of their products is a very good example
of liberty in the face ofless safety. 1 do not
smoke. I think dgarettes stink and I think
that addicts are weak for not facing their
addictions. However, I would and will defend
mightily the right of a company to market
cigarettes through honest commerce.
By the way, I like beer with my Chee-tos.
- [anine
~ "
ONE HOUR'S WORTH OF SUBJECT LINES IN
THE REAL HEALTHCARE E-MAIL INBOX
LJ free information about commodity trading
VJ Re: Subscription to Real Healthcare
>< legal concern? we can help.
:d Fw: Fw: SF Gate: Evil Evildoers Of Evil
::-<: Re: editorial thing
>-J Re: Re:You Guys Really Suck
Pill Adds 1 to 3 inchs to penisGuarenteed
20 FreeGirl Pies. Hot
rs:_:<; I am not subscribing to Real Healthcare
Fwd: [ed] Re: Anthrax
How do I subscribe?
l'-( U SAVE ON MORTGAGE PAYMENTS
Re: pinsky suave
Lunch?
l>-< gamine: Dictionary.com Word of the Day
:sJ INCREDIBLE NEW INCOME CONCEPT!!
:q Editorial profile for Real Healthcare
g Medscape's Managed Care Medpulse
N Anemia, Transfusion, and Mortality
ts: Leather Jacket Sale!!
UNSUBSCRIBE IMMEDIATELY!
ts: Thanksgiving?
Running out of current issues
The product they dont want you to have ...
Earth to Janine, come in Janine, over.
H Copy of Article in CO Sept 99 Vol 5, #3
>< Manuka Honey revolutionizes wound care
Re: Evolution
VJ Fw: Blue Shield anger letter
YJ Walmart Wines
:':.o:J Re: New Magazine: Real Healthcare
M Re: Clarity vs. Snippy
comment on your initial issue
The lancet TOC:: Vol 358 Issue 9291
r:;;:: Press Release: BIOTECH REVOLUTION!
t< Re: humor

real heolthcore
don't/didn't have the man/men wear two
condoms at once since it is safer, and safety
is everything. Oh, you may not be heterosex-
ual, it is true, and California will need to
know that, of course, because studies show
that lesbians have the highest rate of domestic
abuse, so we may need to target that behavior.
Of course you won't mind these intrusions in
the name of your highest ideal: health.
I see that you also don't like "beer, junk
food and coffee," so we have a glimpse as to
where you might next turn your attention
after you are satisfied that smoking has
evanesced. (By the way, when would that be?
Should the state continue to attack smokers
until all smoking has been eradicated?
Should it continue until there are fewer
deaths from smoking than are due to diet,
and then we start attacking people who eat
junk? Shall we be in a permanent state of
Orwellian health war?)
When high cigarette prices lead to the
smuggling and violent crime always associat-
ed with prohibitions and quasi-prohibitions,
may we hold you accountable for contribut-
ing to this health hazard? It isn't as though
we don't know that prohibitions have hor-
rendous health consequences since we have
two morality and health campaigns, against
alcohol and drug users, to inform us.
Moral crusaders such as yourself -in the
name of health- prefer to ignore history. Not
only is the history of prohibition ignored,
but you show no awareness of the Nazi
obsession with health. Much of what the
Nazis did was in the name of social hygiene.
It provided the basis for the Final Solution,
planned and executed by physicians. The
Nazis, too, disapproved of smoking. This is
not very tasteful ideological company.
You wrote that Dr. Gipe read a Ben
Franklin quote after the WfC catastrophe,
but you are oblivious to the irony. When
Franklin said, "They that can give up essen-
tial liberty to obtain a little temporary safety
deserve neither liberty nor safety," he could
very well have been referring to those who
support the use of state power to prevent
people, in the name of health, from engag-
ing in private and consensual behaviors. He
could have been referring to you. The
American founders toiled rigorously and
courageously to rid citizens of state intrusion
into their personal lives, but they were not as
wise as you and the State of California. They
didn't realize how important health was,
careless men and women that they were.
Ben Franklin did not make an exception
for health, and he did not envision a state
that would (literally) dictate personal risk. He
meant what he said, and what he said is the
very opposite of the campaign against smok-
ers and cigarette makers.
Very much at the core of this issue is the
right of Americans to self-medicate. Much
like the right to trade freely, the freedom to
self-medicate was presumed so inviolable by
the founders that they didn't bother to spell
it out in the constitution. Thomas Jefferson
would not have imagined that his habit of
using laudanum (opium) would, if engaged
in 200 years later, not only block his ascen-
sion to the presidency, but land him in jail
for years or decades, and his "pusher" per-
haps for life. (Since Jefferson is said to have
grown opium in Monticello, perhaps he was
the "pusher" for himself and others.)
As George Washington, another reported
opium user, has instructed us, "Government
is not reason, it is not eloquence, it is
force ... " In the last century, Americans gave
away the right to freely accessible drugs in
exchange for the imagined safety of govern-
ment coercion that would protect the com-
munity by preventing people from treating
themselves with narcotics.
This paternalism quickly expanded so
that we are allowed to use no drug that the
government says we cannot, and in most
cases we must have the permission (prescrip-
tion) of government agents (physicians)
before doing so. There are still small rear-
guard skirmishes over this issue, for instance
by those who want to protect the right to
self-medicate with herbs and nutrient supple-
ments, or use marijuana for various maladies.
But for the most part Americans are content
to trade their liberty to self-medicate for the
illusion of safety.
The essential issue is moral rather than
practical, but studies show that more people
die as a result of the Food and Drug
Administration blocking the access of
Americans to drugs that are available in
other countries than are prevented from
dying by stringent testing requirements. Of
course, the hundreds of millions of dollars in
regulatory costs to bring a new drug to mar-
ket also inhibit innovation and cost addi-
tional lives.
I am not and have never been a regular
tobacco smoker, and have never received any
money from a cigarette company. I don't drink
alcohol or coffee. I have inhaled marijuana.
Nicolas Martin
Executive Director,
American Iatrogenic Association ttc