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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?
You simply ban plastic surgery that could be reasonably expected to worsen the patient. Which includes worsening their aesthetics to a substantial enough degree. And then you revoke the licenses of doctors doing this. Of course you apply this to the trans issue too. This should apply in general. With sufficiently harmful procedures, you also criminally prosecute the people undertaking them for harming their patients.
So, if you are a rich guy, and even if not, and want to spend your money on hair transpant, trt, plastic surgery, you should be able to, provided that the operation will actually improve you. Or at least, not harm you. Although public funds should prioritize medical needs. With TRT the health side effects are such that it should be restricted until you reach people of sufficiently old age and low testosterone where it might be good for them.
So it should be allowed if it improves the patient and if rich people spend more on it, then that is fine.
If it worsens the patient, to an understandable degree, then it doesn't matter if they want it, and there is someone willing to provide it. It should not be allowed. Including restricting harmful drugs. Allowing some room for subjectivity and gray areas, and lack of knowledge though. Also, to take into consideration risk before surgery and whether if things go wrong is because it was foreseeable, or statistically it would happen over a large enough tries.
I mostly agree.
The "it can't be stopped" is defeatist cope that can be applied on anything. The reality is that enforcement gains or loses ground and an attitude like this gives ground. It is the pro criminal fallacy that "if I don't do it, someone else will" of a corrupt society. In this case "If they don't do it, others will". The more people buy into this, the more you find your society captured by crooks.
Armenian doctors might be less likely to do such procedures than American doctors and if American doctors were unwilling to do this, then it is more likely that it might not have happened, or happened less.
Who's going to be the beauty police?
Mastectomies probably don't need a subjective standard.
IIRC that one Oriental vizier-themed blog considers any breast reduction surgery a crime if it brings you below E cup, the ideal male preference.
A good Schelling fence is it ain't none of the government's business what's "good aesthetics". Looking back at history, would you really trust them with that? I don't.
I wonder if he's aware that his preference aligns with back problems and doesn't care, or if he's just never actually dated a skinny girl with E cups.
I do think there's a regulatory role for plastic surgery for minors, I think we can define major deformity pretty well. Something that would make shopping at Walmart difficult, though that's hardly a scientific test.
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