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.”

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)

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

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?

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?

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?

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.

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.

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?

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?

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)

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)

Medicalization

Dreger’s comments reflect a tendency to medicalize an ever greater number of things

– Shortness– Childbirth– Relationship Problems in DSM V?

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?