Your Voice

April 1, 2005

Public health: How far should government go?Regarding “Getting England into shape: Is there a lesson for the United States?” (Editorial, January 2005): I take issue with Dr. McMillan’s conclusion that the only way to solve the problem of unhealthy lifestyle choices is to legislate common sense and individual behavior. The freedom to indulge in an unhealthy lifestyle is what distinguishes the United States from socialized countries. We would probably all be healthier wearing shoes and hats and warm clothing in winter (and not smoking, having premarital sex, or piercing body parts), but our government has not yet taken on the responsibility of clothing the entire populace. And we would all be healthier without inhaling second-hand (and first-hand) smoke, but I instead vote with my choice of restaurants and the public places I attend.

Why should the British National Health Service stop at banning smoking in pubs? Why not just make it illegal to smoke at all, anyplace at anytime, and put all the smokers, who are costing the British health-care system all that money, in jail, where they can be fed and clothed for the rest of their lives? When such an attitude is taken to its inevitable conclusion, it doesn’t make sense.

As individuals, we do need to take responsibility for our lives. Regrettably, some people will make bad decisions (just as parents who use drugs, smoke around their children, allow them to watch TV and play computer games all day, and don’t insist that their children use seat belts, car seats, and bicycle helmets or eat healthily, endanger themselves and their children). But, as Abraham Lincoln said, you can’t make people better in the long run by doing for them what they should and could do for themselves. I’d rather not live in a country where every “choice” is made for me by a government that professes to know my best interest. After all, the government may decide that women should not have abortions, or more than two children, or work after having a baby, or that we should never eat chocolate, watch television, or see sexually-oriented TV commercials.

Diane A. Butler, MD
Parma, Ohio

Author reply: My editorial questioned whether public health efforts might be more effective than the one-on-one involvement of pediatricians in influencing behaviors that jeopardize the health of children. Dr. Butler’s letter indicates that she places herself at one end of the continuum in the discussion about whether unhealthy behavior should be legislated away or tolerated, even when the unwise choices of parents affect the health of their children. She is certainly correct that individuals should take responsibility for their decisions, and I acknowledge that there is a limit beyond which each of us would not want government to go in legislating “common sense and individual behavior”-although that limit may be at a different place for Dr. Butler than for others. Should we tolerate all bad decisions on the part of individuals? Should there be no restrictions on unsafe driving, for instance? The argument has been that such laws are needed because speeding drivers and those who ignore stop signs put others at risk. Cannot the same be said for those who smoke in public places?

When I cited the campaign of the British government to improve the health of its people, I did not intend to suggest that the United States follow suit. As described in my editorial, much of the British effort will rely not on restricting unhealthy behavior but on encouraging improved nutrition and exercise, including the use of incentive programs and education. The question of government financial support for healthy behavior is as important as the discussion of personal freedoms. Should we be paid to exercise?

Decisions about legislating behavior and about financial support for activities that promote health are being made every day in state legislatures and in Congress. Those decisions affect pediatricians, our families, and our patients. At the very least, it is important that we participate in the discussion and that we insist on assessment of the outcome of those decisions. Reducing speed limits does, in fact, save lives. Now that we know that, it’s appropriate to ask whether those lives are worth the limits on our individual freedom.

Julia A. McMillan, MD

Painful look at a transgendered personI was surprised to see the motion picture “Boys Don’t Cry” as a recommended resource for families in the article “To the beat of a different drummer: The gender-variant child” (February 2005). The movie is about the real life of a girl in Nebraska who pretends to be a boy. Her life ends with her rape and murder, which are directly related to her gender-variant behavior. I don’t think this is the type of resource that families with a gender-variant child would want to view-I can only see it infusing more stress, fear, and anxiety into their lives.

Marty Allison, MD
Pierre, S.D.

Author reply: Dr. Allison rightly points out that the movie “Boys Don’t Cry” may be extremely painful and upsetting for some viewers. Pediatricians should qualify their recommendation accordingly. The film avoids sugarcoating the dark aspects of this real life story-the rape and murder of Brandon Teena-and provides the only realistic and sympathetic portrayal of a young transgender man widely available for video rental. Therefore, it has an important place in educating physicians and patients.

The protagonist in the movie is a female-to-male transgendered person; it is important to avoid trivializing the lives of transgendered persons by using such expressions as “a girl who pretends to be a boy.” What defines a person’s gender is the deeply felt sense of being male or female.

The inexcusably violent crimes perpetrated against the protagonist in the film reflect the demeaning attitudes that abound in our society about people who are not gender-conventional and heterosexual. The problem that fuels those crimes is the negative stereotype and stigma associated with being different, not the person’s gender-variant behavior, just as racism-motivated crimes are not caused by the victim’s race. Youth who are rejected by their families are at risk for the worst outcomes. We believe that education about gender-variant children will provide the best protection for them and their families.

Pediatricians can best serve their patients by being aware of the existence of this motion picture and by being prepared to discuss it. Many teenagers struggling with issues related to sexuality, and parents looking for answers, will find this film on their own, whether we recommend it or not.

Edgardo Menvielle, MDCatherine Tuerk, MS, CS, RNEllen Perrin, MD

Yet another diagnosis to considerLyme disease should have been included in the differential diagnosis of the patient with pseudotumor cerebri (aka benign intracranial hypertension) (Puzzler, January 2005). Of course, this would depend on season of presentation and geographic location of the patient. Antibody tests of serum and cerebrospinal fluid (CSF) and, possibly, polymerase chain reaction for Borrelia burgdorferi of the CSF should have been performed.

Kevin A. Slavin, MD
Hackensack, N.J.

Author reply: Dr. Slavin is correct. We did not specify the location of the patient in this case; she was from Houston, where we have not had a case of Lyme disease in recent memory.

William Risser, MD