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How Do We Stop Doctor Shopping
TLDR: If one is attempting to gatekeep a treatment, whether surgical or pharmaceutical, that is important for some patients but that other people may seek to access for reasons we find unacceptable, behind physicians and medical standards, how does one prevent doctor shopping? How does one prevent a sufficiently wealthy or connected individual from trying doctor after doctor until they get what they want?
My wife and I were discussing SCOTUS granting cert for USA v. SKRMETTI (link to petition, link to lower court decision here) a case in which the Justice Department is attempting to overturn a Tennessee law banning medical transition for minors. I commented that I saw no path forward for the case at SCOTUS, because they don't even bother in the petition to argue that Tennessee lacks the power to regulate medical care. The petition repeatedly cites WPATH standards, so recently discussed here, as though their existence writes itself into Tennessee law or the US constitution automatically. No matter how many times the petition uses the term "evidence based;" I'm left wondering where in the Constitution the legislature is required to act based on evidence. The core of their argument is around equal protection:
The decision from which they appealed concluded that:
It seems to me that the state has the power to regulate medical treatments within its borders.
Being straight, as one occasionally must, I then listened to my wife bring up Kylie Jenner and her adventures in plastic surgery. I have to admit my wife has a point, the 26 year old woman looks at least 40. Her face is weirdly contoured, filler has wandered around, and her breasts are kinda detached from her body at some angles. Why, she asked, is it legal for her parents to get her plastic surgery, starting her on a path that has permanently altered and ruined her body; merely because those procedures were gender conforming? Because the weird "negroid-barbie-doll-centaur" Kardashian look is undoubtedly feminine rather than masculine, Kylie and her parents are unrestricted in making insane changes to her body?
I replied that it would make sense to ban plastic surgery for minors, and that Tennessee would certainly have the power to do so, and that I'd support a total ban except in cases of extreme deformities. How would you define extreme deformity, she shot back. Well, I guess you'd need a doctor to certify it. Gotcha, she said, that wouldn't stop Kylie or her parents for a second, they'd have crooked Armenian doctors on tap anywhere they needed them.
And it occurs to me that I have absolutely no idea what the next step in that process is. How do you gatekeep medical procedures against the well resourced?
In law school I knew lots of people who doctor shopped. First for a certification of "disability" that would grant them extra time on entrance exams, then for adderall prescriptions. ((I honestly felt they ought to piss-test before finals, addys were such a problem.)) They all fit the same criteria: well connected, wealthy families, people who often knew lots of doctors personally and had the resources and support to try multiple to get the diagnosis they were looking for to get what they wanted.
I've no doubt that if a diagnosis of "deformity" were required for cosmetic surgery, many women would suddenly be diagnosed with deformed breast tissue. I've already heard of plenty of use of creative diagnoses to get things covered by insurance policies.
Maybe it's lack of knowledge, but I'm at a loss as to how one fights this. A blanket ban on trying a different doctor seems like it would run dangerously close to banning second opinions, and I've seen many second opinions that massively improved on the first doctor's results. People should be free to keep trying if one doctor can't get results. But how do we distinguish the case of an individual trying to find help for a condition, from an individual without medical training settling on a pill they want to pop and trying doctors until they find one who will let them pop it?
This has obvious pharmaceutical implications. Adderall, Xanax, Oxy have all been abused. But what about things like TRT? Plastic surgery? And of course it comes back around to Transgender Kids: if somebody takes their kid to three doctors and they all say the kid isn't trans, but drags them on to a fourth doctor who says they are, is the kid trans or not?
I can't think of any good way to draw the line. At best we can rely on professional ethics, but, you know, lol. What's the strategy here?
I don't have an answer to the actual question you're asking besides you can't and probably shouldn't. People should be allowed to make decisions about their bodies and before they're old enough to consent to those decisions we can't do much better than relying on the parent's responsibility to act in their children's interests. Will some parents do irreparable harm in a failure of this responsibility? Absolutely. Does it mean that gating any treatment behind a doctor's evaluation is basically pointless for anything that could plausibly be granted? Also yes. But the alternatives seem worse. If we think a treatment is categorically wrong or wrong given objective criteria like age of recipient then we should write laws that do that. The fight is properly had on the ideological level and the motivation for such a procedure if it can't be won there then it ought not be won on these obscure proxy grounds.
I think it’s actually necessary in some cases. Things like surgery or drugs you don’t actually need can present lots of risks to patients. Surgeries can go wrong leading to infection or internal bleeding or the like. Drugs can be dangerous in themselves, especially if they have a low fatal dose or are highly addictive. This is actually how we got so many people hooked on opioids. Some people obviously need them, but at the same time, the drugs were so addictive that people would go to great lengths to get them including doctor shopping. There were “pain clinics” in some parts of rural America that were giving out more prescriptions than there were people in the town.
I think honestly the best approach isn’t to regulate patients, but doctors. If a doctor was on notice that over-prescription of scheduled medication would trigger an audit of his practice, he’s unlikely to be a pill pusher. If you’re going to get a similar audit for recommendations of surgery at rates far outside the norm for your specialty, then, again, you’re going to be a bit more careful about that sort of thing.
The problem I see with doing this on a one-size fits all legislative scale is that there will always be edge cases or extraordinary circumstances that can make the procedure necessary even if on paper the procedure can’t be done.
So does life.
So can playing football, or learning to use power tools, or white-water rafting, or cooking.
You can make the same claim about swimming pools.
How large is the doctor-auditing agency you're planning to run, such that it has the capacity to evaluate any meaningful percentage of practicing doctors? And who's staffing it? Are line doctors going to be second-guessed by the type of people who currently disproportionately work in government jobs? Good luck with that.
And even this doesn't stop the problem - it just pushes the issue one step further up the chain. Now you're looking for doctors who are either willing to fake the books (increasing the danger to the people undergoing the procedure because black markets are incredibly unreliable) or who have political pull with the auditing agency. We already see this all over the place; the last head of the California Department of Alcoholic Beverage Control, which regulates and polices significant limitations on alcohol manufacture, wholesale, and marketing, resigned in order to take a job as...an alcoholic beverage control compliance specialist at a high-power law firm!!
You can't stop people from making shit decisions.
I think the difference in medicine is specifically that the people using the service are generally in no position to understand the issues involved. Most people don’t have even a high school understanding of human biology. They don’t understand enough to know if something is dangerous or not. What most people end up doing is treating medicine like they would have treated witchcraft 800 years ago— the guy in funny clothes told me I have to eat/drink this or let him do this thing to me. They don’t have any expertise or experience to say “hey wait, is this really a good idea?”
With things like swimming pools or other sports or activities, a person is in a bit better shape in making a good decision because they know what they’re looking at. If my kid wants to go swimming, I know whether he has that skill, I know whether he’s going to a pool or a river or lake, I can therefore have a reasonable assessment of the risks. If he wants to play football, I’ve seen enough football to know it’s a rough sport with a fair number of injuries. Alcohol is again something people know enough about to make reasonable decisions about. They know it can be addictive they know it impairs judgement and coordination and they have probably seen a drunk uncle or two.
As far as the agency I’d use — most states already have medical boards with all kinds of record keeping, requirements to keep up with the field through continuing education hours, requirements for the facilities, requirements for outcomes. Every state already has this, you have to have a state medical license to practice medicine (and a similar thing for pharmacies) in any given state. I don’t see a problem with adding a check that you’re not giving out opioids or adderall at 2σ above the normal base rate and having someone check up if you are. If every child coming to your psychiatrist practice is being diagnosed with gender dysphoria, then there’s very likely a problem, just like if you’re giving every single person coming to your clinic adderall or OxyContin.
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The risk vs benefit of swimming pools vs opiates is far different. Swimming pools don't give you cities where part of the place is taken by drug zombies. It is relativism to act as if they are comparable. And so it goes for many things. There is a line to be taken, and refusing to support a line ends up with predictable large problems. Because you can in fact have a society of different levels of corruption and harmful behavior.
You aren't really encountering in this thread safetyism purity spiral supporters. There isn't a sufficient negative to swimming pools, even if a small percentage of people using them and having fun swimming (and improving cardiovascular health possibly in doing so), end up drowning.
An important point to mention, is also as the ancient Greeks, Romans, Christians, and others understood, and through continuity through the ages wise people understood, is the problem of people being enslaved to their passions. The drug addict not only harms his health, but is fundamentally not a free man. This is also bad for the group as a whole since from a collective point of view, such behaviors degenerate society.
It isn't an accident that "Do what thou wilt shall be the whole of the Law" is so identified with the modern Satanist movement. Even from a secular perspective, it tells you something that this is the philosophy of a movement that adopts the symbol and name of evil and sin, in accordance to the dominant religion of western civilization. The attempt of inversion of morality, leads predictably to an immoral code that harms civilization.
That's true, but if I recall correctly, when I was looking at different causes of death in the United States, swimming pools turned out to kill a similar number of people (mostly young kids) to accidental gun deaths in the United States annually. Obviously, you'd have to compare the base rate of pool ownership (as well as time spent around the pool) to the rate of drowning to get good numbers on the actual risk of owning a swimming pool, but I wouldn't blame a less risk-tolerant person if they didn't own a swimming pool because they were concerned about the risk of their own kids drowning.
I think the problem with bringing up "safeteyism" is that there is obviously a point in any situation where anyone except the most committed libertarian would eventually agree a law of some kind is necessary for society's well-being. Many regulations are written in blood, and I understand the impulse of a person who is more likely to ask "are the trade offs of enforcing this regulation worth it?" rather than "does this regulation reduce individual liberty?" or whatever. Sometimes it takes an unregulated amusement park ride decapitating the son of a state senator for a law to be written.
That’s because accidental gun deaths are a trivially small problem because the sorts of people who own guns are more likely to be responsible with them than average.
This person does not want to have to maintain and/or pay for a swimming pool, and is telling his wife it’s too dangerous as a trump card.
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That says more about accidental gun deaths than it says about swimming pools.
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You can limit the harms of people’s shit decisions and put barriers in place to deter them making the worst ones.
That said, I agree with the spirit of what you’re saying. I tend towards being maximally permissive about self-funded medical procedures by adults. From plastic surgery to suicide, as long as the state isn’t contributing a penny, you’re a compos mentis adult, and no-one else will be directly harmed, then I see no good reason for imposing any significant limits. Minors are obviously a very difficult case, and deserve greater protections.
You can put rules in place. But that only works so long as people either (a) voluntarily follow the rules - which, if they really disagree with the rule and really want to do the thing it forbids, they won't - or (b) can be forced into doing so. And the powerful, wealthy, or well-connected will always be able to disproportionately slip the net.
You don't have to make a rule to cover literally 100% of people such that they can never evade it. 99.8% is good enough. A better rule for 99.8% of people is better than a crappier rule for 100%.
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