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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?
Well, first, you can't. But second, who cares?
I don't mean that in a dismissive way--I mean, has "but that law seems difficult to enforce" ever been a legible reason for striking down (or refusing to adopt) a law against something dangerous? There are countless laws against illicit drug use. Many of them are, at least arguably, stupid, but their stupidity is a political question, not a question for the courts. (At least until an activist court decides to get fancy with "arbitrariness," I suppose...) People use drugs, and it's bad for them, and explicit government disapproval of their activity does seem to actually reduce those harms (see: Oregon) even when it can't be said that the relevant harm can be eliminated entirely.
Ultimately, if enough people are down with transing the kids, the kids are gonna get transed. The threshold of "enough" is simply a question of power: if you've got a lot of money, then just knowing one willing (or venal) doctor will probably suffice. But if you're a middle class parent hoping to engage in a little light Munchausen's by Proxy for internet karma and GoFundMe credit, you're going to need some extra assistance via e.g. insurance, tax subsidies, and maybe some government bullying of recalcitrant health professionals. Conversely, simply making a law against transing the kids will suffice for 99% of the population, just like all the other laws that rich people so often find themselves free to disregard.
Sending a message. Having a government that doesn't directly contribute to harming children based on dubious pop culture trends and the elevation of mental illness to a virtue. Protecting children from abusive parents. "But they don't think it's abuse!" Fucking tough; I'm happy to outlaw genital mutilation (including male circumcision), too, because my conception of child abuse is unmoved by appeals to moral relativism. If states can't outlaw transing kids, then they can't outlaw the genital mutilation of infants, either--not in any principled way.
This isn't directly on point, but I think the case against male circumcision has been overstated by advocates and adopted by guys who were circumcized as infants and wouldn't know the difference. A friend of mine nixed his foreskin at age 23 and said there was no real difference once he recovered from surgery. Contrast that with the experience of my mother, who spent 30 years as an outpatient surgery nurse and said the number of guys who come in for surgery do to recurring problems (usually UTIs), is enough for her to put the anti-circumcision crowd on the same level as anti-vaxxers.
What about all the other countries in the world where it is a strange and abhorrent practice? If you're not a dirty retard you're not going to get a UTI from being uncircumcised, who is your mom interacting with? I take it you got clipped and have some motivated reasoning going on here.
Numbers I've seen show that the risk of UTI in uncircumcised infants is 10× that of circumcised infants. The numbers drop to 6× in childhood and 4× in adulthood. The infant number is what they're most worried about, though, since infants can't exactly communicate symptoms easily and untreated UTIs at that age can cause kidney damage and all sorts of other problems. I'm not that motivated on either side of things, but I'm irritated with the activists out there who act like circumcision is mutilation akin to sexual anesthesia. There are clear benefits, and whether those benefits outweigh the disadvantages is something to take into consideration, but the disadvantages are often overstated.
I know for my mother the risk of severe complications from the surgery (very rare approx 2-6/1000) was decisive in deciding against it.
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Don't women get a lot more UTIs than men? I don't think it is as big a deal as many do, I know tons of people both circumcised and not, it hasn't impacted anyone's life that much. The ultra online people crazy about it are often damaged in a lot of other ways, and this is an easy thing to fixate on. Very Freudian really. You should see some of the crazy Propecia related ED forums, the insane corners of the internet are insane. But anti snip part of your peen off people are not in line with anti-vaxxers. The gripe they have is legit medically speaking, humans don't need to have their foreskin removed.
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