Thursday, February 17, 2005

Comments on Comments

SmileyI have turned off comments on the site for now. After my last post, I received a flurry of comments, the basic premise of which was that I was an arrogant physician who cared nothing for patient autonomy, was a greedy SOB, and that I -- and all doctors with me -- deserve to be sued out of our BMWs. And that was the warm, fuzzy icebreaker -- it went downhill from there.

Now, far worse things have been said about folks on the Internet. But what was evident in the comments was the presumption that physicians are arrogant and greedy, and deserve every lawsuit they get and more. Most of the negative comments were anonymous.

Comments on a blog are a decidedly mixed bag. They are public, and become part of the post. This can be a good thing: well-thought-out comments may challenge the poster's facts or suppositions, or may add significant information on the topic which enriches the overall post. This is true even of negative comments, posted respectfully. Conversely, the anonymity of the Web seems to bring out the worst in some people. The idea that you are going to win someone over to your point of view by starting a conversation with a stranger, impugning their character and integrity, and smearing their entire profession, frankly strikes me as a bit odd, and certainly stupid. There is a great deal to impugn in my character, and no shortage of character defects and shortcomings, -- but that is why I have friends and family. They have earned the right to point out my defects based on a mutually strong and trusting relationship, and I accept such criticism -- though unpleasant -- far more readily. But from an anonymous moron on the Web with an ax to grind? Yeah, right. The public nature of such comment flame wars tends to demand a response, which in me brings out the snarky, sarcastic, condescending side of my nature. This is a character flaw I would rather not practice to perfection. Furthermore, there is barely enough time to post semi-intelligent essays on this blog. Devoting additional time to extinguishing ill-willed flamethrowers is utterly pointless.

And let's get a grip, folks. This is a personal blog. It is a labor of love, a useful tool to help me organize my thoughts, and hopefully provide some value to others. If you enjoy reading, I'm grateful, and appreciate your interest. If you're bored, perhaps some other post may be of more interest, or there's a million other blogs to interest you. If it enrages you to the point of seething anger, perhaps the issue is less me than you, and you most certainly need to find some other more enjoyable and less stressful activity. Of course, if you just want to spew venom at strangers whom you dislike or hate, perhaps it's time to do a little soul-searching of your own. Just do it elsewhere, please.

For now, readers who appreciate these posts and want to express that, or want to contribute other thoughts or corrections, are more than welcome to e-mail me. If you strongly disagree with me, and wish to carry on a conversation in a mutually respectful manner, I am more than open to that, time permitting. I most certainly do not have all the answers, and will treat every such e-mail with respect it earns. If you just want to rant and seeth, do whatever you need to do to vent your rage: kick your dog, punch the wall, sacrifice a goat to Satan, whatever it takes. But please don't waste your time, my time, or my readers time with this drivel.

One point raised by my erudite detractors is worth repeating, since my response in the comments is now hidden. This is the issue of patient autonomy. For me personally, -- and for every physician I know -- patient autonomy is extremely important. The myth of the paternalistic physician snapping orders to the passive and demure patient is utterly out of touch with reality. The common thread of comment criticism was that, as a patient, you pay me your money, and you get therefore to dictate my services. This is an extremely contractual view of the physician-patient relationship. My job is a physician is to use my skills, training, experience, and intellect to determine the nature of the patient's disease or problem, to educate them on the treatment options available, and make recommendations when appropriate. The patient is entirely free to accept or reject my recommendations. I may encourage them not to reject them, and explain the potential adverse consequences of such a decision, but it is their decision entirely. There is one important distinction, however. The patient is not free to demand that I performed a service or treatment which is unethical, or which I know to be harmful to the patient. This is both my responsibility and my autonomy in the relationship. If you find that arrogant, well, tough.

This is the exact point I was trying to emphasize in my prior post: the patient is entirely free to reject a recommendation that his testis be removed, because of the high risk of cancer, knowing that a small percentage of that time there will not be cancer present. He is not free to demand that I perform a biopsy which will pose a significant risk to his life or health, where the risk far outweighs the benefit. Patient autonomy is not unlimited, although it is broad. Physicians are constrained morally and ethically from doing harm to patients deliberately, no matter what the patient demands of them, or the economics involved. A society which penalizes physicians who make such moral and ethical choices, by means of lawsuits or otherwise, is one which will live to regret the destruction of this boundary.

Update: Thanks to the many folks who wrote and encouraged me about comment trolls and asking to restore comments. I'll turn them back on this weekend -- albeit with a short leash on morons. As I've said, I don't mind disagreement (in fact, I encourage other viewpoints -- "as iron sharpens iron", etc.), but ad hominem attacks on me or against other commenters, or otherwise abusive comments, will be deleted and IPs banned. Battling the morlocks is not a productive use of my time. But I am deeply grateful to those who appreciate the blog - come back often, and leave comments!