Saturday, October 22, 2005

*Doctors and Public Policy*

Right from the outset allow me to establish that I have nothing against doctors determining public policy. However, the criteria on which I judge the policy is going to be very much dependant upon the soundness of that policy. And that must necessarily include the fact that there are not experts in every area of politics, that they are medical doctors and not necessarily research scientists and that for every cause there must be an effect, even unintended ones.

So I'm glad that Minister of State for Health, Dr. Balaji took time to address the call by some doctors (including I think the head of the National Cancer Centre) as to a COMPLETE ban on tobacco related products and smoking in Singapore. And he made a number of good points, amongst which was that you would create a culture of criminality not unlike what happened during the prohibition i.e. illegal smuggling, black market, criminal elements controling the purchase and sale of tobacco related products etc. and make criminals of people who were simply unfortunate enough to pick up smoking and not be able to quit in time. This is especially so when they are currently and perfectly within their legal rights to do so. The other point he made was with reference to the tourism industry, and the likely massive downturn in it.

Unless we start touting ourselves as a smoke free nation. Which is something I have tremendous sympathy with because I hate the smell of smoke and there'll always be some inconsiderate smoker.

I'll admit I have no idea what the doctors' policy is going to be like. But if I had to implement such a policy, I would probably make it a staggered event and implement it gradually. I would probably also institute a nationwide kick the habit programme which would treat all smokers as addicts and addiction as a medical problem and probably start aggressively handing out nicotine gum and patches as well as sending them to rehabilitation centres. I'm not sure if we're going to allow them to smoke overseas though.

But I wonder if anyone is going to draw parallels with the legalisation of drugs and start to think through the issue a little more than simply have a visceral instinct that says no on the basis that drugs are bad. I will honestly have to admit that it is well beyond my capabilities to argue that currently illegal drugs should be legalised in Singapore. The best I can go will probably be for drugs that are less addictive and damaging to health than cigarettes and other tobacco related products. Off-hand, the only 'recreational' drug that fits this bill I can think of is marijuanna but I would be willing to hazard a guess there might be more.

But there is a point I would strongly like to emphasise that was not mentioned explicitly in Dr Balaji's speech and that is that the 'gateway effect' of soft drugs is likely to be much higher when they are illegal than when they are legal. The gateway effect basically postulates that after a while you want to get a more intense high and therefore you move to harder drugs. I think this confuses drug tolerance for usage of harder drugs. It is more likely that a person would simply take more of the drug than suddenly want to shift to a harder drug. And the reason behind why this gateway effect seems to exist is that soft drugs are not the money spinners for drug pushers. As a result, if you need to get soft drugs you must get them from people who want you to move to harder drugs. There is quite some proof for that when you examine the number of hard drug users under 20 in the Netherlands where access to soft drugs is legal and contrast that to the US where it is not (and prosecuted much much heavier). In the US, the figure is about 20% whereas in the Netherlands, it is a mere 1.2% and I think there's much to be said where if you want a kick you don't have to associate yourself with the underworld.

Extrapolating from the above, if you ban tobacco related products, you're going to drive these smokers into the welcoming arms of there drug dealers and that is seriously going to cause more harm that the smoking related deaths currently.

Please don't get me wrong, I think smoking is insanely dangerous and should be curbed and I applaud the government's efforts to reduce the number of new smokers to zero and to encourage existing ones to quit. And instead of a seriously draconian measure, they are a number of other ways we could achieve the same result like for example giving smokers more limited access to heart and lung transplants for example or hiking the taxes again.

In a similar vein, I think a question needs to be raised as to what exactly or how exactly we should approach the authority due to medical doctors as personnel trained in the art of medicine and surgery when it comes to issue of a patient's decision to end his or her life at the terminal stage of cancer. Because when one phrases it in the above fashion, a doctor doesn't have any intrinsic authority to impose his or her decision on what is essentially a personal and private one on the part of the patient.

A doctor is meant to consider what is in the patient's best interests and it is worth noting that the hippocratic oath was merely one of the several floating around when well he came up with it. As such, if all we are concerned about it that the doctor has to grant the patient's wish through say an overdose of morphine then we could well and simply delegate it to someone else. Not unlike how the state does not use doctors as executioners during capital sentencing.

In conclusion, though I respect doctors for what they are, I do not think they have any more moral authority when it comes to an area perhaps not quite within their expertise as authorities and also when they make policy simply on the basis of medicine. Beware the law of unintended consequences. There always will be one.




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