Medicynic

It’s alway puzzled me that taking innumerable vitamins, of dubious utility and origin, appealed to the “natural healthy food” crowd. These supplements are pushed, presumably for a fee, by various “experts” who are anything but expert–such as Kathie Gifford, various athletic types, Suzanne Somers and all manner of fading B-list celebrities. These people, and they include health gurus such as Andrew Weil, are willing to sell you their own brand supplements at a substantial profit to themselves.

Proponents of health lifestyles and “organic foods,” don’t hesitate literally ingest handfuls of these remedies and vitamins of uncertain origin and dubious efficacy. They take them to “stay healthy” while berating our health care system, ironically, for prescribing too many pills.

The use of vitamins to prevent disease is a little like the man from Sri Lanka I once met in Pennsylvania wearing flower in his vest. When asked why? He replied “it keeps the elephants away.” When I told him there were none here, he nodded and said, “see it works.” When he returns to Sri Lanka it won’t continue to work.

The best way to stay healthy is to eat well, exercise and not use tobacco products. There is little evidence that indiscriminate use of vitamins do much of anything. To true believer of vitamin use, however, vitamins appear work for most of their lives (most of us are healthy for most of our lives) and then they don’t.

In fact virtually all of these “health store” remedies are unproven and in many instances have been proven harmful to the health. Yet billions of dollars are wasted on them each year.

The FDA has been reviewing over the counter “natural” diet pills and found that they contain dangerous ingredients and may do significant harm to harm.

“And StarCaps are not the only culprits. In a continuing investigation that has prompted consumer warnings and recalls by some distributors, the F.D.A. has determined that dozens of weight-loss supplements, most of them imported from China, contain hidden and potentially harmful drugs.”

“Doctors said undeclared drugs could cause problems on their own, like elevated blood pressure or seizures, could have toxic interactions with other medications and could make it difficult for physicians to diagnose patients.”

How do such products get on the market? In the 90’s when the use of over the counter (OTC) agents was accelerating, Orin Hatch of Utah, the home of many of the supplement companies, sponsored and got passed through the republican congress the Dietary Supplement Health Education Act of 1994 (DSHEA)–Clinton signed the bill. Before DSHEA manufacturers of OTC remedies had to prove to the FDA that their supplement was safe. The idea that they might have to prove that the remedy did anything was never a part of the FDA review process.

After the act was passed, the FDA, already short staffed and underfunded, had to discover and prove that a “dietary supplement” was unsafe before they could stop its sale. What followed was feeding frenzy of marketing of agents for such indications as “heart health”, “prostate health,” “male enhancement,” and all manner of vague indications. Just as a stopped clock is right two times a day there are occasional useful supplements. Unfortunately,however, most are useless and some as noted above cause significant problems.

The FDA has a list of potentially harmful dietary agents on their site.

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Patient Autonomy taken to a ridiculous level.

“The births were a hot topic of conversation Friday, with many people incredulous that a woman with six children would try to have more — and that a doctor would help her do so. Several doctors said it is not their role to dictate family size.”

“Nadya Suleman and her other six children, who range from age 2 to 7, live with her parents in Whittier, a Los Angeles suburb.”

“Angela Suleman said all the children are from the same sperm donor, but she did not identify him. She said that her daughter is divorced, but that the ex-husband is not the father.”

“Friends and family said Suleman worked as a psychiatric technician until she was injured on the job several years ago. Then she began having children and enrolled in college, earning a bachelor’s degree in child and adolescent development and returning to pursue a master’s in counseling before dropping out last year.”

Guess who is going to pay?

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Part of the ethical basis of our health care system is that patients have autonomy.

“The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.”

Ideally, physicians provide information, explain alternatives, options and implications but the patient makes the decision. However, despite this, patients often make bad decisions. For example, patients with terminal illness with little or no chance of response or recovery may decide on the most aggressive, toxic, and costly treatment option. As a result, he/she may have more problems in their last days and the expenses for care in the last six months of life may exceed the all the expenditures for health care in that person’s life.

The physician’s influence should not be discounted. Most doctor’s explanations and recommendations are in the best interest of patients. However, physicians because of the nature of fee for service can have conflicts of interest that influence their behavior. The more they do, the more they make. Other factors such as the physician’s research interest, or financial interest in laboratory or imaging facilities may also affect decisions.

Pharmaceutical companies and other providers of health care technology influence patient decisions through promotional activities. Drug companies spend more on advertising than on research. Physicians are barraged with advertisements, “educational” opportunities and company propaganda. Lay people are deluged with media advertisements touting the benefits, with scant disclosure of toxicity and cost, of new drugs and technological advances. In many instances the new products are no better than older more cost effective agents. All of this is about influencing patient autonomy.

The cost of patient decisions is buffered by our system of insurance. With an insurance based system after paying the insurance premium someone else pays. Costs are under-represented in the care decisions. The patient wants to live a full and healthy life. The physician runs a business and like all businesses it has to generate enough money to pay expenses and salaries. Suppliers of services and health technology have the fiduciary responsibility to make a profit. Insurers, in addition to paying for care of their beneficiaries, also want to make money for their stockholders. Nowhere in our system is an objective balance to the universal incentive to spend more.

Our republican friends want a system that places greater financial responsibility on the patient. That would certainly increase patient concern about costs. But it would also eliminate most people from the health care system because the price for care would exceed the ability to pay. This creates the ethical dilemma of people with diseases who are unable to afford health care. Are we as a country willing to allow these sick people to die because of lack of access? At this point only very wealthy very insensitive people seem to favor this solution.

The question then is how to raise the level of cost consciousness in an insurance based system. A system that maintains the concept of patient autonomy but also provides efficient affordable services. The answer is not simple and will be part of the challenge that faces Secretary Daschle and the Obama administration.

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