Friday, September 6, 2019

Epidemiology, biomedical 'causation', and my widow-maker: how to make sense of it, and what terms to use

As I've posted previously, I have been recovering from multiple bypass heart surgery.  I had some angina, vague superficial chest pain that is a symptom of impending heart attack (or, more properly) coronary artery blockage.  Fortunately, I am educated enough to recognize that this chest pain wasn't from my doing a new kind of exercise, I went to the doc and--to make a long story short--was sent right off to the hospital for heart bypass surgery (replacing clogged coronary arteries).

The radiography showed that at least some of my heart arteries were clogged--with whatever radio-opaque goop, presumably including cholesterol, and by whatever clogging mechanism.  These causal facts are, as I understand things, complex and not completely understood, but the upshot was clear: surgery.....or else!

Now, the doctors would say that, given this evidence, I was at high risk of potentially lethal heart disease.  I'm sure had the opportunity been there (and it may be in some future doctor's appointment), I will be chided--or scolded--for my bad diet, too much cholesterol, etc.  It will be assumed that my voluntary lifestyle choices caused my blockage and my need for preventive artery replacement.  Bad boy!  Bad diet! Tsk, tsk, tsk....

But is that right, or might it be the opposite of a more serious truth?

What is bad behavior, health-wise?
I am 77.  This is beyond the usual 76-ish life expectancy for US males (searching the ad-laden web to find data has become mainly a challenge to wade through the relentless commercialism).  So, my lifestyle cannot be viewed as bad behavior in this respect.  Indeed, I have already lived longer than half my birth cohort!  So perhaps my diet and whatever else can, or should be viewed as having been protective.  After all, I was symptom-free until after my expected lifespan.

It is very difficult to understand what 'risk' means in such regards.  If my lifestyle led to my artery becoming clogged up, but it didn't happen until after I'd out-lived my average peer, can I legitimately think of that lifestyle as having been protective rather than risky?  We all have to get some final disorder and some point, so is the absolute cause the relevant fact, or is it the relative?  How can we decide such questions, if indeed they are meaningful ones that can even have meaningful answers?

If my behavior (for whatever reason, including just plain luck) led to my surviving in very good health, except for one weakest-link, then does that link suggest I've behaved badly, or does my overall great state of health suggest the opposite?  More to the point, how can such questions even be answered in a meaningful sense?  They seem meaningful....until you think a bit more carefully about them. . . . .

The philosophical quick-sand doesn't stop there.  If my arterial clog would have led to a relatively quick death--not a 'premature' death at my age!--but saved me from some worse, more prolonged or debilitating fate, can we seriously view that as preventive or protective, with me now facing those dreadful fates?

When we have competing causes and inevitable mortality, we have to view the causes, and what causes them, in a rather different light.  That doesn't mean there are consensus, much less easy, answers.  But it may mean that rules for 'healthy' behavior are not so obvious as they seem to be.


Unknown said...

I still read your posts and value the observations and reflections. One of the dangers of a blog is that responses may not be on target or even in the playing field. Still, I don't resist posting this poem I read today from Garrison Keillor's "The Writer's Almanac." It reminded of this post in particular.

by Wendell Berry

I know I am getting old and I say so,
but I don't think of myself as an old man.
I think of myself as a young man
with unforeseen debilities. Time is neither
young nor old, but simply new, always
counting, the only apocalypse. And the clouds
—no mere measure or geometry, no cubism,
can account for clouds or, satisfactorily, for bodies.
There is no science for this, or art either.
Even the old body is new—who has known it
before?—and no sooner new than gone, to be
replaced by a body yet older and again new.
The clouds are rarely absent from our sky
over this humid valley, and there is a sycamore
that I watch as, growing on the riverbank,
it forecloses the horizon, like the years
of an old man. And you, who are as old
almost as I am, I love as I loved you
young, except that, old, I am astonished
at such a possibility, and am duly grateful.

"VII." by Wendell Berry from Leavings. © Counterpoint, 2010

Take care of yourself and I hope you continue writing.

Ken Weiss said...

Thanks. The ravages of age are interesting....if only they just happened to somebody else instead of me!

James Goetz said...

Dear Ken, I'm glad your back and still writing. Human health is as complex as you describe. Take care and keep blogging. James :-)