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The Trouble with Normal

The Trouble with Normal. ISD II – Endocrinology Jan. 22, 2002 Andrew Latus. When Should Physicians Treat Someone?. “To some, treating disease and restoring health, the ‘well-working of the organism as a whole,’ is the proper aim of medicine.”

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The Trouble with Normal

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  1. The Trouble with Normal ISD II – Endocrinology Jan. 22, 2002 Andrew Latus

  2. When Should Physicians Treat Someone? • “To some, treating disease and restoring health, the ‘well-working of the organism as a whole,’ is the proper aim of medicine.” • The question then is whether the patient “has a disease, ‘an abnormal functioning of an organism that impairs normal physiological functioning.’” (Allen & Fost, 1990, 18)

  3. In Other Words… • When Should Physicians Treat Someone? • If X has an abnormal condition • and that condition impairs normal physiological functioning • and X wants the condition corrected • and we can do so • then it’s morally OK, maybe even required, to treat the condition

  4. What’s Normal? • Notice that the idea of what’s normal does a lot of work in the answer just given. But what’s normal? • Is normal a statistical notion? • i.e., is it a purely descriptive idea? • Is it a normative notion? • i.e., does any assessment of something as normal or abnormal involve an evaluation of the thing as somehow good or bad?

  5. Normal Isn’t a Purely Statistical Notion • At least for medical purposes, the idea of what’s normal doesn’t seem to be a purely statistical notion • Suppose we discovered a way of correcting a heart problem that will eventually occur in 51% of the population (assuming they live long enough) • Now suppose we have a patient who has lived long enough that this condition threatens his life • Are we not morally required (or even not permitted) to operate because this condition is not abnormal, statistically speaking?

  6. A Further Problem with the Statistical Idea of Normal • Even if we try to treat normal as a purely statistical notion, there is still room for evaluative considerations to creep in via the frame of reference we pick • E.g., when we ask whether a height of 5’ 3’’ is abnormal, what comparison group should we have in mind? • All people? All males? All white males? All protestant males? All Canadian males?

  7. Normal is a ‘Mixed’ Notion • Statistical assessments of the commonness of a condition are not irrelevant to assessments of whether treatment is morally OK • But they do not tell the whole story. • An element of evaluation is always, or almost always present. • Generally, this poses no problem since it is usually clear whether a particular condition should be evaluated as bad or not.

  8. A Harder Case: Treatment with GH • Johnny is a short 11-year-old boy with documented Growth Hormone (GH) deficiency resulting from a brain tumor. His parents are of average height. His predicted adult height without GH treatment is approximately 160 cm (5 feet 3 inches). His parents want Johnny treated with GH. • Billy is a short 11-year-old boy with normal GH secretion according to current testing methods. However, his parents are extremely short, and he has a predicted adult height of 160 cm (5 feet 3 inches). His parents want Billy treated with GH.

  9. Is There a Moral Difference Between the Two Cases? • Most will consider it OK to treat the GH deficient child • What about the child who is likely to turn out to be short for other reasons? • His predicted height is statistically abnormal (given the right frame of reference), but should we evaluate it as something it is acceptable (or required?) to treat?

  10. Allen & Fost’s Response • “GH responsiveness, not GH deficiency, should be a criterion for GH therapy… [T]he primary goal of GH therapy should be to alleviate the handicap of short stature, rather than the treatment of GH deficiency…” (Allen & Fost, 1990, 17) • Why say this?

  11. When Is Something ‘Broken’? • “ The [American] Academy [of Pediatrics] statement concluded with the old adage ‘If it ain’t broke, don’t fix it.’ But what exactly is ‘broke’ when it comes to short stature and GH therapy?” • “’broke’ cannot be defined simply by GH deficiency, because given enough GH, most children’s growth rate and, perhaps, ultimate height can be increased.” (Allen & Fost, 1990, 18) • So broke means ‘can be improved’? • Note their view on steroid use (p. 19)

  12. A Response • “…I see ever more cases in which psychosocial problems caused by stereotypes about anatomy are being ‘fixed’ by ‘normalizing’ the anatomy.” • “Instead of constantly enhancing the norm – forever upping the ante of the ‘normal’ with new technologies – we should work on enhancing the concept of normal by broadening the concept of anatomical variation.” • “If you can fix it, you should”? (Dreger, 1998)

  13. Medicalization • Dreger’s comments reflect a tendency to medicalize an ever greater number of things • Shortness • Childbirth • Relationship Problems in DSM V?

  14. What Can We Fix? • Would it be OK to use hormones to fix someone’s height? • Would it be OK to surgically correct deafness? • Would it be OK to lighten someone’s skin? • What’s the difference between these cases?

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