#TL09C: TO WHAT DEGREE DOES HEALTH DEPEND ON CHOICE?

Edited and compiled by Frederick Mann
Copyright © 2002 Build Freedom Holdings, ALL RIGHTS RESERVED

Introduction
The first part of this report consists of a discussion during January, 1997 on the Professors of Liberty mailing list on the topic "To what degree does health depend on choice?". The text of this discussion is included below.

The second part provides a guide for searching the Internet in order to gather information to indicate to you what kind of choices might be available to you in respect of preventing and/or treating diseases and conditions.

The third part briefly describes some important personal choices I've made.

Part 1: Professors of Liberty Discussion

Date:      Sun, 5 Jan 1997 15:47:03 -0500 (EST)
From: "Daniel Shapiro" <U027D@wvnvm.wvnet.edu>
Subject:   Health and choices

I had always thought that it was uncontroversial that it was mostly
people's bad habits that played the largest role in determining whether
they died prematurely of heart attacks, cancer, etc.  In the sense in
which habits are matters of choice, then I thought that it was peoples
choices that played the largest role in determining what kind of health
risks they face.
   However, in _Benchmarks of Fairness for Health Care Reform_ by Norman
Daniels, Donald Light and Ronald Caplan (Oxford, 1996) they state flatly
that "most health risks are not affected by choices" (p.46).  I suspect
that they are using "choice" here in a way that implies that bad habits
are not a matter of choice, but in case they are not I want to know
whether my belief about bad habits and health risks is correct.  Can
anyone on the list give me one or two reputable references that
summarize the facts about one's health status and choices? I am
addressing this in particular to the two doctors I am aware of on this
list (Bob Sade and EMF), but anyone who can provide information, I'd
appreciate any leads you can give me.
    Thanks much.
    Danny Shapiro

Date: Mon, 6 Jan 1997 10:14:09 -0600
From: pence@uab.edu (Greg Pence)

        It is the current fashionable health ideology that people's choices
(habits) determines their ultimate health, but there is little evidence for
this claim.  It is more a wish to control fate.
        The Human Genome Project is already providing a useful antitode to
this view: as genes are discovered for breast cancer, prostate cancer,
Huntington's disease, etc., it becomes increasingly obvious that some
people will get sick regardless of choices or habits.

Greg Pence
Department of Philosophy & School of Medicine

************************************************************************
greg pence
dept. of philosophy & school of undergraduate medicine
u. alabama at birmingham (uab)
pence@uab.edu         phone/voice mail 205 934-8922      fax 205 975-6639
*************************************************************************

Date: Mon, 6 Jan 1997 08:41:53 -0800 (PST)
From: Fred Foldvary <ffoldvar@jfku.edu>

On Mon, 6 Jan 1997, Greg Pence wrote:

>         It is the current fashionable health ideology that people's choices
> (habits) determines their ultimate health, but there is little evidence for
> this claim.  It is more a wish to control fate.
>         The Human Genome Project is already providing a useful antitode to
> this view: as genes are discovered for breast cancer, prostate cancer,
> Huntington's disease, etc., it becomes increasingly obvious that some
> people will get sick regardless of choices or habits.

That's great news, since I no longer need to watch my diet or do
exercises.
Can you cite the evidence that refutes the claim that genes create a
disposition to certain diseases which are then triggered by
chosen factors such as diet, pollutants, and exercise?

Fred Foldvary

Date:      Mon, 6 Jan 1997 14:49:25 -0500 (EST)
From: "Daniel Shapiro" <U027D@wvnvm.wvnet.edu>

I don't see how what you said shows that choices (habits) don't play a
signfiicant role in affecting one's health status.  Unless genes
literally determine one's health status so that one will get, e.g.
prostate cancer regardless of one's diet, whether one smokes, etc., then
I would say that choices (habits) play a role, perhaps a signficant
one. If, for example, one has the genes that predispose one to getting
prostate cancer, but one's chances of getting it are far greater if one
eats a high fat diet or smokes, or doesn't exercise, whatever, then it
seems clear that habits have played a significant role in the onset of
the disease.
   Of course,one could deny that that choices are involved if there is
a genetic component or predisposition. But since all of human behavior
persumably has a genetic component, then one would be committed to the
claim that there are no choices.  Daniels et. al (the authors I cited in
my previous note) do not claim, however, that there are no choices.
   If I am missing something, please let me know.  Thanks,
   Danny

Date: Mon, 6 Jan 1997 14:32:42 -0600
From: pence@uab.edu (Greg Pence)

"I don't see how what you said shows that choices (habits) don't play a
 signficant role in affecting one's health status.  Unless genes
 literally determine one's health status so that one will get, e.g.
 prostate cancer regardless of one's diet, whether one smokes, etc., then
I would say that choices (habits) play a role, perhaps a signficant one."

Yes, that's exactly it.  If you have the Huntington's gene, you get HD
regardless of whether you smoke, exercise, etc.  If you have BRAC1, the
first  breast gene discovered for breast cancer, your chances are 87% of
getting breast
cancer versus 14% without it.  My hunch is that the Human Genome Project is
going to reveal many, many genes like BRAC1.

  It's not that choice has NO effect on health, but rather, much, much less
than those of us want to believe who exercise, eat correctly, etc.
Single-gene diseases now have been discovered for more and more conditions.
The current issue of DISCOVER lists the diseases for which genes were
discovered in 1996.  If you have the gene, say, for retinoblastoma, there
is nothing you can do to prevent its occurrence.

Of more interest to health, thousands of multi-gene diseases will be
discovered within the next decade that act together to produce illness and
dysfucntion,  That's partly what the Human Genome Project is all about.

At a distinguished medical lecture a few years back, an internal medicine
professor from Hopkins went through all the evidence for increased
longevity.  The most important factor by far, he concluded, was the age of
of death of your 4 grandparents.  If you sum these ages and divide by 4,
you have an 80% chance of dying within 2 years of that figure.  His
conclusion, "The best thing you want to live to an old age is to inherit
good genes."  (Note: the 2nd most important factor was drinking clean
water)

There is also some evidence that exercise actually INCREASES morbidity and
mortality, especially if you include accidents and injuries from
high-impact sports and heart attacks incurred while doing strenous
exercise.

Finally, I'm not saying that there's evidence that NOT exercising will make
you live longer, but I AM claiming that there is very little evidence that
exercise and diet will cause you to live longer.  Even in the Harvard study
of WM over 50, many critics have pointed out that people who are
genetically more fit and healthy are far more likely to exercise and eat
well (because they are more successful at it, get more reinforcement, etc)
and hence, there is a hidden cause ascribable to genetic inheritance.

best wishes,

greg pence

Date: Mon, 6 Jan 1997 19:20:44 -0800
From: EMARAT@HARVARDA.HARVARD.EDU

Greg Prance writes:

>>Yes, that's exactly it.  If you have the Huntington's gene, you get HD
regardless of whether you smoke, exercise, etc.  If you have BRAC1, the
first  breast gene discovered for breast cancer, your chances are 87% of
getting breast
cancer versus 14% without it.

  It's not that choice has NO effect on health, but rather, much, much less
than those of us want to believe who exercise, eat correctly, etc.
Single-gene diseases now have been discovered for more and more conditions.
The current issue of DISCOVER lists the diseases for which genes were
discovered in 1996.  If you have the gene, say, for retinoblastoma, there
is nothing you can do to prevent its occurrence.<<

It's just not that simple.  Some things depend on a single gene
but most diseases are multigenic and environmental factors (i.e.
behavior and life style) contribute.

Look at the risk factors for heart disease:

You've got sex, weight, hypertension, cholesterol/tri-glycerides,
conditioning (excercise), smoking, diabetes, family history.

Sex and family history are genetically determined.  Weight
is in part voluntary in part a genetic predispostion.  So
is blood pressure -- you're less likely to have it if
you eat a low salt diet.  Diabetes is linked to weight
so it's partly related to behavior.  Smoking? Well starting
to smoke is a voluntary act.  Heart disease is the number
1 cause of mortality in males in the United States.  Would
changing life style impact on heart disease -- yes.
Off course people would die of something else.

>>Of more interest to health, thousands of multi-gene diseases will be
discovered within the next decade that act together to produce illness and
dysfucntion,  That's partly what the Human Genome Project is all about.<<

In the next decade?  No way -- there aren't that many researchers
to go around.  Maybe by the quarter century.

>>At a distinguished medical lecture a few years back, an internal medicine
professor from Hopkins went through all the evidence for increased
longevity.  The most important factor by far, he concluded, was the age of
of death of your 4 grandparents.  If you sum these ages and divide by 4,
you have an 80% chance of dying within 2 years of that figure.<<

Only works if your grandparents live in the same environment as you do.
If they were peasants or if they lived on a shetl and had barely
enough to eat and you live in New York City and dine out every night
it won't apply.

>>>>>>>>>>>>>>>, but I AM claiming that there is very little evidence that
exercise and diet will cause you to live longer.  Even in the Harvard study
of WM over 50, many critics have pointed out that people who are
genetically more fit and healthy are far more likely to exercise and eat
well (because they are more successful at it, get more reinforcement, etc)
and hence, there is a hidden cause ascribable to genetic inheritance.<<<

Exercise to the point of cardiovascular conditioning decreases
the likelihood of cardiovascular events.  Exercise is prescribed
after myocardial infarctions to decrease the likelihood of
a second MI.  Exercise is good for you because it enhances insulin
action and because it builds collaterals around the heart.
Given the choice I'd opt for good genes over exercise but if
you don't have the choice exercise helps you make the best of it.

Eleftheria Maratos-Flier
Department of Medicine         Research Divison
Harvard Medical School         Joslin Diabetes Center

Date: Mon, 6 Jan 97 23:07:26 PST
From: Elisabeth Ryzen <ryzen@SMI.Stanford.EDU>

As one of the few physicians on this mailing list (and one who is typically
silent, I have a serious problem accepting the idea that environmental and
lifestyle factors play only minor, if any, roles in the pathogenesis of
diseases.  Despite the fact that over the last decade or so genetics research
in general and the Human Genome Project in particular have helped to increase
our understanding of genetic factors involved in the pathogenesis of certain
diseases, there is little doubt that environmental and lifestyle
modifications can alter the expression of genetic predispositions to many
diseases and ailments modern man suffers from (though not as completely as we
would like).

At one extreme we have rare diseases like Huntington's which , as far as I
know, are purely genetic in origin.  I'm not aware of any evidence that
jogging 10 miles a day, eating granola and a low fat diet, and refraining
from smoking prevent development of the disease in a genetically susceptible
person.

At the other extreme are diseases which are (theoretically) 100% avoidable
through appropriate lifestyle modifications.  HIV, from which 30,000,000
people worldwide suffer, is an example of such a disease.  If people do not
engage in the high-risk activities known to spread the AIDS virus, they do
not get AIDS.  Similarly, if people don't drink 2 quarts of vodka a day (or
the equivalent), they don't get alcoholic liver disease (thought they may get
liver disease from other causes).

Most diseases appear to fall somewhere in between the two extremes.  For
example, we know that obese people (1/3 the U.S. population) are more likely
to have, among other diseases, hypertension, heart disease, diabetes, gout,
and degenerative arthritis.  Conversely, we know that losing weight often
lowers blood pressure, cholesterol, and blood sugar.  Often even patients
with a strong family history of diabetes will not develop clinical diabetes
unless they become obese.  We also know smokers have much higher risk of
heart disease, peripheral vascular disease, lung cancer, head and neck
cancer, and emphysema.  Conversely, NOT smoking or stopping smoking lowers
the risk of developing these diseases or slows their progression.  The data
supporting these facts are there and obvious to those of us who see patients
and read the medical literature.  But we have trouble explaining the
90-year-old sitting in his rocking chair chainsmoking all day, consuming a
diet of fried chicken, gravy, and buttered biscuits.

Analysis of that 90-year-old's genes and environmental factors, including his
lifestyle, in detail, may tell us more about what we can do to prevent
development of the diseases he seems almost immune to.  Similarly, we know
only a minority of heavy drinkers get alcoholic liver disease -- why?  Not
everyone exposed to HIV contracts the virus -- why not?  Not everyone who
contracts HIV does equally poorly -- why not?  Why is it easier for some
people to quit smoking or overeating than others?  Are they missing a "free
will" gene or complex of genes, qualitatively similar to the genetic
abnormality recently allegedly linked to clinical anxiety?  Are drug abusers
missing a "moral responsibility" gene?  Currently, there are only partial and
inadequate answers to these questions.  The possible philosophical and
ethical (not to mention insurance industry) implications are open to debate.

Deciding if a "majority" or only a "minority" of human disease is
:"genetically" or "environmentally/lifestyle" determined doesn't seem to be
the key issue, and in any event, I don't think it can be decided at this time
tiven our current state of knowledge.  A small change in definitions could
cause great differences in the answers.  I saw this despite frequent
statements in medical journals that 50-75% of diseases in the U.S. are
lifestyle problems.

What seems more important is gaining a better understanding of the precise
roles genetic and environmental factors play in each disease and health
aberration we know of, including addictive behaviors and psychiatric
disturbances, so as to better be able to positively alter
the course of these problems.  This is no small task.

Elisabeth Ryzen, M.D., J.D.
Staff physician, Palo Alto Department of Veterans Affairs
Clinical Associate Professor of Medicine, Stanford University

Date: 7 Jan 1997 15:52:40 -0500
From: "Robert Sade" <robert_sade@smtpgw.musc.edu>

        Reply to:   RE>Health and choices

In his original communication on this topic, Danny Shapiro said:
*   However, in _Benchmarks of Fairness for Health Care Reform_ by Norman
Daniels, Donald Light and Ronald Caplan (Oxford, 1996) they state flatly
that "most health risks are not affected by choices" (p.46).  I suspect
that they are using "choice" here in a way that implies that bad habits
are not a matter of choice, but in case they are not I want to know
whether my belief about bad habits and health risks is correct.  Can
anyone on the list give me one or two reputable references that
summarize the facts about one's health status and choices?*

The first part of Danny's question is easy to answer: there are good sources
of factual information on health effects of lifestyle choices.  One of the
best studies is JM McGinnis and WH Foege, Actual causes of death in the United
States, JAMA, 270(Nov 1993):2207-2212.  They showed that 50% of the deaths in
the US are related to lifestyle choices: in order of importance, they are
tobacco use, diet and activity patterns, alcohol, sexual behavior, motor
vehicle accidents, and use of illegal drugs.  Lots of other studies look at
particular habits and their relationship to morbidity and mortality.

The more difficult issue, though is the second part of the question:  what are
the health costs of 'choices'; that is, which if any of the above habits and
behaviors are actually chosen--to what extent are they genetically programmed
and therefore inevitable (predetermined)?  Daniels, I am sure, is a
determinist on this issue, given his generally paternalistic attitude in
bioethical matters.

I am skeptical that behaviors with a genetic component are as predetermined as
many believe.  For example, there are genes that affect behavior with alcohol,
and the recidivism rate after treatment of alcoholics is  high, upwards of
90%, regardless of the nature of the treatment.  Clearly, the story goes,
alcoholics cannot 'choose' not to drink. IF, however, one's liver has been
destroyed by alcohol and one needs a liver transplant, most candidates stop
drinking for the required 6 months, and once a liver transplant has been done,
the recidivism rate (counting as few as one drink as a relapse) is so low (11%
at 3 years post-transplant) that the survival of patients and of transplanted
livers is nearly the same as those of nonalcoholics.  Impending death is a
strong motivator in choosing not to indulge in bad habits.  Alcoholics may not
often choose not to drink, but they _can_ choose.

Best regards.  --Bob
___________________________________________________
Robert M.  Sade, M.D.
Professor of Surgery
Department of Surgery
Medical University of South Carolina
171 Ashley Avenue
Charleston, South Carolina 29425
Office telephone--803 792 5278; Page operator--803 792 2123; Office fax--803
792 8286; Home telephone -803 723 2148; e-mail--sader@musc.edu

Date: Fri, 10 Jan 1997 13:33:28 -0800

   I forwarded part of the discussion thread "Health and choices" to
a life-extension mailing list (the CR Society) and received the following
reply:

 -------------------------------------------------------------------------

Thanks John, for forwarding an interesting discussion.

I think, however, that the question can be answered without need of
discourse on inherited defects and behavioral genetics.

Those who believe that genetics has an absolute role in lifespan
need to ask themselves a question:  "Why is it that identical twins
die, on average, seven years apart"

(Intrapair differences of physical aging and longevity in identical
twins. Hayakawa et al, Acta-Genet-Med-Gemellol-Roma. 1992; 41(2-3))

Steve Chambers

Date:         Fri, 10 Jan 97 22:13:49 EST
From: Eleftheria Maratos-Flier <EMARAT@HARVARDA.HARVARD.EDU>

John McPherson forwarded:

>>I think, however, that the question can be answered without need of
discourse on inherited defects and behavioral genetics.

Those who believe that genetics has an absolute role in lifespan
need to ask themselves a question:  "Why is it that identical twins
die, on average, seven years apart"

(Intrapair differences of physical aging and longevity in identical
twins. Hayakawa et al, Acta-Genet-Med-Gemellol-Roma. 1992; 41(2-3))

Steve Chambers<<

OK, well the average male life expectancy in the US is 71 and
the female life expectancy is 79.  So a seven year difference
represents a difference of <10% for men and 8.8% for women.

For a biological systems this represents _small_ differences.
=/- 10% is good if you're doing an experiment with animals.
Indeed depending on the actual data the 7 year difference
may be +/- 5% on average.

This suggests that identical twins die at similar ages, e.g.
if one twin dies in the sixth decade the second twin is likely
to die in the sixth decade.  If one twin makes it to the ninth
decade the second twin is likely to make it to the ninth decade.

Sounds like a pretty good support of the genetic basis of longevity
to me.

Eleftheria Maratos-Flier, M.D.

Date: Fri, 10 Jan 1997 21:35:34 -0800 (PST)
From: Fred Foldvary <ffoldvar@jfku.edu>

On Fri, 10 Jan 1997, Eleftheria Maratos-Flier wrote:

> Sounds like a pretty good support of the genetic basis of longevity
> to me.

Do you think a disposition to libertarianism is a result of a gene?
Perhaps some biologist will discovere the "libertarian gene" that turns
people into libertarians.  Most likely a recessive gene.
We will then stop trying to convert the world towards liberty, because
those without the libertarian gene will never become libertarian.
A few, very few, people will be observed born with two libertarian genes -
these become radical anarchists.
The next step will be a government program to test embryos for the
libertarian gene, and apply gene therapy to stamp it out.

Fred Foldvary

Date: 11 Jan 1997 07:28:29 -0500
From: "Robert Sade" <robert_sade@smtpgw.musc.edu>

                    RE>>Health and Choices                       1/11/97

Fred Foldvary said:
*Do you think a disposition to libertarianism is a result of a gene?
Perhaps some biologist will discovere the "libertarian gene" that turns
people into libertarians.  Most likely a recessive gene.
We will then stop trying to convert the world towards liberty, because
those without the libertarian gene will never become libertarian.
A few, very few, people will be observed born with two libertarian genes -
these become radical anarchists..*

This may not be so far-fetched.  As I recall, the Minnesota study of identical
twins reared apart showed that conservatism (presumably defined as desire for
stability) versus liberalism (desire for and acceptance of change) are
consistent among adult identical twins separated at birth, suggesting a
genetic basis.  I don't know if they ever looked for a libertarian trait
(?aversion to the use of force unless defensive?), but it wouldn't be
surprising if it had some genetic component (for example, Milton&Rose and
David Friedman, supporting your two recessive genes-lead-to-radical-anarchism
conjecture).

Best regards.  --Bob

From: Pierre_Lemieux@UQAH.UQuebec.CA
Date: Sat, 11 Jan 97 18:03:03 -0500
Subject: Libertarian gene

It seems to me, on the basis of anecdotical evidence, that
the libertarian gene is dominant, not recessive.
This might not help much, though, as many historical
figures of libertarianism (including Ayn Rand, Lysander
Spooner, Georges Palante, Benjamin Constant, etc. -- see
my "The individualist sentiment" on my Web site) were
so socially handicapped that they died childless...
Pierre Lemieux
http://www.spinnaker.com/Pierre_Lemieux

Date: Mon, 13 Jan 1997 10:46:04 -0500
From: jnarveso@watarts.UWaterloo.ca (Jan Narveson)

As a fascinated layman, I want to thank everybody who has contributed to
the discussion of "health and choices". I, for one, have learned a lot!

__________________________________________________________________________
Jan Narveson (Professor)
Department of Philosophy, University of Waterloo;
Waterloo, Ontario, Canada, N2L 3G1
(519) 888-4567-1-2780# (from touch-tone); or 885-1211, ext. 2780 (via
switchboard); FAX (519) 746-3097 Home: (519) 886-1673 (answering machine)
e-mail: jnarveso@watarts.UWaterloo.ca

Part 2: How to Determine the Choices that Can Make a Difference
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