Doctors must factor in free will of the patient

Originally published in The Ottawa Citizen January 7, 2003
Original Title: Millions for Prevention: Is anyone listening?

The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you would rather not. – Mark Twain (1835-1910)

As soon as a question of will or decision or reason or choice of action arise, human science is at a loss. – Noam Chomsky (1928- )

A recent front-page story in the Citizen remarked how a Health Canada anti-tobacco campaign using Olympic skaters Elvis Stojko and Josée Chouinard did not have much influence on reducing or quitting cigarette use. Indeed, how effective are health promotion campaigns?

A National Post article (Death: What are the odds?, December 31, 2002, page B3) reviewed the ten most common causes of death by disease in 1989 and 1999 for men and women (see inset). Some diseases are on the decline yet others such as lung cancer in women have surpassed breast cancer. Flu and pneumonia are on the rise partly due to an aging population, smoking, other chronic disease states and an aversion to flu vaccine.

Certainly, there are educational health advisory programs to combat disease. Societies and organizations do their best to inform the public about treating and preventing injuries and disease. They do an admirable job.

Yet as a physician, I continue to see many people who do not heed the sage advice of health care professionals and organizations. Perhaps it is the overwhelming nature of the health information. The mind has a tendency to turn itself off when overloaded. Ask any patient with type 2 diabetes about the plethora of diabetes health information, diets, medical tests and procedures following their diagnoses. Further, the health arena is replete with differing views and advice.

There are limits in our ability to digest (pardon the pun) the latest news about the foods and nutrients in our diet, medical studies, prevention programs and general health advice.

To wit, this is a partial list of diseases and conditions amenable to prevention, eradication or reduction of damage with early diagnosis and screening:

  • Diabetes, heart disease, hypertension, congestive heart failure, stroke, kidney failure
  • Emphysema, chronic obstructive lung disease, asthma
  • Colon, breast, prostate, skin, cervical and lung cancer
  • Depression, panic disorder, obsessive compulsive disorder, suicide, bipolar disorder, schizophrenia, eating disorders
  • Liver failure, hepatitis A, B and C
  • Chlamydia, gonorrhea, human immunodeficiency virus (HIV), herpes simplex, human papilloma virus (HPV)
  • Tetanus, diphtheria, polio, mumps, measles, rubella, meningitis, whooping cough, influenza A and B, typhoid, chicken pox
  • malaria, water-borne parasitic and bacterial diseases
  • peptic ulcer disease,
  • fractures, head injuries
  • motor vehicle injuries

Family doctors advise their patients about all these relevant topics at the appropriate time. We have to prioritize prevention advice and screening based upon the individual’s age, lifestyle, past medical history, family history and screening tests.

“Prevention” is the buzzword heard in discussions about primary care reform (PCR). The hypothesis is that preventing these diseases would reduce human suffering and health care system expenditures. The implication of this statement is all people will cooperate and follow the recommendations of their doctor or other allied health professional. To quote Hamlet, “Ay, there’s the rub.”

What do you do when a patient refuses a treatment despite your best efforts to persuade them that it will prevent future illness? Cigarette smoking is a good example. I know a charming diabetic asthmatic father of a four-year-old girl. She asked him if he loved her. “Of course I do”, he responded. “Then stop smoking because I don’t want you to die”.

Yet he continues to smoke. He feels guilt and shame and knows very well what will befall him if he remains on his present path.

Many people know of someone in the same predicament. Despite all the education and effort to prevent disease, human nature does not fit into a predictable neat package. Throwing more money into primary prevention will not change this crucial component of health care. The very nature of human responses to disease (fear, denial, anger, and concerns about loss of independence among others) can disrupt any prevention program. Indeed, patient non-compliance to therapy is a leading cause of deteriorating medical conditions and hospitalizations in Canada.

Even with the advent of computerized records to recall patients for specific blood tests, cancer screening programs and disease-specific follow-up appointments, it remains with the patient to assume the responsibility for their own health care. Health care professionals cannot track every iota of their patients’ lives micromanaging each of their potential risk factors for disease.

The Canadian Task Force on the Periodic Health Exam provides age-specific guidelines to help physicians prioritize the relevant tests and procedures for their patient. Each person requires an individualized approach to prevention and treatment. This approach includes the person’s willingness to participate in his or her own health care.

PCR states that the present system does not encourage doctors to provide preventive care services. In fact, many physicians do provide this service. Indeed, it is a family doctor’s responsibility to prevent as well as treat disease. We can offer the appropriate tests and procedures to screen for cancer and prevent disease but rarely does any program or system ever achieve 100 per cent success.

There will always be people that require treatment despite illness prevention campaigns. Although sometimes it leads to better health, other times not, people must be free to choose for themselves.


  1. Heart disease — 200.3
  2. Lung cancer — 73.2
  3. Stroke — 47.4
  4. Chronic airway obstruction (asthma, emphysema, etc.) — 27.8
  5. Flu and Pneumonia — 24.8
  6. Colorectal cancer — 23.6
  7. Suicide — 20.8
  8. Diabetes– 14.1
  9. Hereditary and degenerative nerve disease (Parkinson’s, etc.) — 12
  10. Cirrhosis and liver disease — 11.7


  1. Heart disease — 156.4
  2. Lung cancer — 68
  3. Stroke — 42.2
  4. Chronic airway obstruction — 30.7
  5. Flu and Pneumonia — 27.9
  6. Prostate cancer — 23.8
  7. Suicide — 21.3
  8. Diabetes — 20.3
  9. Cirrhosis and liver disease — 9.2
  10. Alzheimer’s disease — 6.1


  1. Heart disease — 147.4
  2. Stroke — 62.1
  3. Breast cancer — 34.5
  4. Lung cancer — 29.9
  5. Flu and Pneumonia — 25.9
  6. Diabetes — 15.5
  7. Hereditary and degenerative nerve disease — 13.5
  8. Chronic airway obstruction — 13.2
  9. Kidney disease — 7.4
  10. Cirrhosis and liver disease — 5.4


  1. Heart disease — 123.4
  2. Stroke — 58.7
  3. Lung cancer — 41.8
  4. Flu and Pneumonia — 31.2
  5. Breast cancer — 30.9
  6. Chronic airway obstruction — 21.6
  7. Diabetes — 20
  8. Senile and presenile dementia — 12.9
  9. Alzheimer’s disease — 12.6
  10. Cirrhosis and liver disease — 4.5

Source: Statistics Canada

© Dr. Barry Dworkin 2003

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