"It is our duty, my young friends, to resist old age; to compensate for its defects by a watchful care; to fight against it as we would fight against disease; to adopt a regimen of health; to practice moderate exercise; and to take just enough food and drink to restore our strength and not to overburden it" - Cicero (106-43 BCE)

Treating Cicero's epigraph pars pro toto, it appears that the desire to live longer has been engrained in western culture for quite a while. That desire is, and always has been, the implicit goal of medicine. Yet as our medical abilities began to catch up with this objective during the 20th century, the looming reality of vast increases of our life expectancy has led to the re-evaluation of this primary function of medicine, and calls for a relevant definition of health that addresses the contemporary assumptions and goals about how medicine ought to be practiced.

Over the last 100 years, life expectancy in the west has swelled from 46 to 80 years of age, and over the next forty years is expected to increase in underdeveloped countries from 65 to 75 years of age, increasing the world population by over 2 billion. The risk of over-population is a daunting possibility that will demand address in the near future. From these figures alone, many have argued that as a society, we can no longer afford to take a lassez fair attitude with regard to the pursuit of life elongation.

If asked, many people will deny that they would like to live forever¹. However, we can anticipate that most will complain about the symptoms of aging. For example, I recently watched a video of overweight middle-aged comedian Louis C.K. During his routine, Louis lamented his �worn out� knee, and his doctor's disinterest in treating it. He joked that if he were younger, the doctor would have recommended therapy or surgery, but at his current age he was being asked to accept that his knee is simply �worn out� and beyond treatment. The crowd was very receptive to this series of jokes, for Louis touched on several very poignant topics that most people can relate to: coping with injury, appraising one's personal health, and establishing expectations for the role that medicine will play in alleviating the physical symptoms of our natural aging.

What does it mean to be healthy? A knee wearing out is a foreseeable symptom of normal aging, as are many other unpleasant health events, and it can be challenging to strike the right balance between one's expectation for reasonable health interventions and a humble concession that inevitably, our bodies just do not work as well as they did when we were young. Understandably, Louis takes the stance that the consequences of normal aging do not fit into his theory of personal health. Although many of us may not think that we want to live forever, at present, it is rather inconceivable that we would simply live out our lives with the pleasures of youth and then abruptly and painlessly terminate at some pre-determined, appropriate age.

This is to say that for the most part, in the minds of Americans, to be healthy is to be youthful. Yet we have also developed other definitions and beliefs about health that occasionally contradict with this definition, and as the challenges associated with our ability to live very long get realized in the west, other theories of health have also taken influential precedence. The experience of feeling healthy sometimes has absolutely nothing to do with its effect on lifespan. Risky liposuction, cosmetic over-exposure to the sun, and consumption of fattening food for immediate satisfaction are only a few examples of measures that people take to feel as if they are healthy, at least momentarily, yet are likely to inhibit life expectancy.

The nebulous definition of health is important to consider when establishing the opposite value: what is unhealthy? On your deathbed at 110 years old as you suffer from arthritis, dementia, and prostate cancer, you are certainly not healthy, despite your old age. This generation is especially sensitive to questions about end-of life quality due to the hotly debated case of persistent vegetative state euthanasia and the story of Terri Schiavo�s feeding tube removal in 2005. Some of us have come to resent this image of aging in a society where our life expectancy outlasts our preferred quality of life. As a result, some people decide that it is appropriate to engage in activities that are fleetingly satisfying, even if they are likely restrict life expectancy. For example, young people who begin smoking cigarettes are often aware of the risks, yet continue the habit. Given this tolerance for knowingly engaging in risky activities, it is difficult to firmly establish what is an unhealthy behavior besides actions that are neither fun nor conducive to live elongation.

Of course, other factors affect our decision making about the the activities we engage in besides our definitions of healthy and unhealthy. And, there is still such a thing as making bad decisions. Nonetheless, as we prepare to reform the health care system in America, there is no better time than the present to assess the paradigms that affect our definitions of health, and relate these theories into a model for how healthcare should be facilitated by the government.

Perspectives on the Skeptical Renaissance in Science and Medicine

Perhaps some people make contradictory health decisions because of a growing public skepticism about the merits of medicine and scientific information. This emerging sentiment may be interpreted as a modern day �renaissance� of pre-Enlightenment skepticism about science before Francis Bacon set the stage for inductive empiricism to edge its way into widespread acceptance.

As the scientific method was beginning to establish its conventions towards the end of the 16th century, philosophers including Francisco Sanchez and Michel de Montaigne contributed to the widespread skepticism about the degree of certainty that empiricism could produce, arguing (correctly) that mankind�s senses and cognitive reasoning are unreliable. The cynicism mounted, most famously typified by Rene Descartes �Discourse on Method� in which he concluded that the only thing that we can know with certainty is that we exist (cogito, ergo sum, �I think, therefore, I am�). His conclusion has become much more influential than the ontological arguments he attempted to make to reconcile this deduction.

These natural philosophers struggled with the theory of certainty because they were pursing certainty in an ideal sense of the word. Today, the assertion that we can be unequivocally certain about anything is seen as outrageous to most scientists, yet for a time, this is how science was presented to the public. It seems that after the well-publicized influence that scientists had in the conclusion of WWII and its aftermath (including the atom bomb and the Manhattan Project), the authority of science went relatively unquestioned for several decades as we became enamored with harnessing its strategies to win the cold war. One student I interviewed described his primary education, admitting, �During my primary education, I was taught that science, because it is objective, is able to solve the problems of the world.� Indeed, I�ve seen many friends make poor decisions using the justification that �science will fix it� eventually. Up to a point, many of us regarded science and rationality highly not because we deduced their beneficence, but because we followed the indoctrination of our primary education.

It is frustrating--albeit understandable--that science is taught not as a methodology for investigating the natural world, but as a specific set of facts and theories to memorize. Although these premises are a necessary springboard for the act of conducting modern science (and the importance of developing this theoretical backbone should not be underemphasized, as progress cannot be made in science without an adept understanding of its language), this dogmatic approach promotes bad scientific practices since ideally, scientists themselves should aim to be skeptical of everything, including their own research. After all, Einstein would never have discovered general relativity had he not been skeptical of the application of Newtonian physics to very massive objects. Raising questions about prevailing conventions is, as Thomas Kuhn would say, the structure of scientific revolutions.

Thus, in short, the heart of science is not found in the facts and figures that make up its image, but in the evidence-based process that is rarely internalized, even by some of its biggest practitioners. The certainty it achieves is from the convergence of the evidence from many examinations of a particular phenomena that indicate a certain probabilistic and predictable behavior. Although we cannot control the types of results it achieves, it is important to remember that we can always use it as a "handmaiden" (as St. Augustine and later Thomas Acquinas described of it to justify the coexistence of science and theology) to answer certain questions about the world.

Nevertheless, it seems that once again some philosophers, such as feminist philosopher of science Lynn Hankinson Nelson, as well as the public are struggling with the implicit contradictions of the scientific method itself. Feminist philosophy of science recalls the skepticism of the Middle Ages, raising questions about the existence of true scientific objectivity. Yet without knowledge of the canon of the philosophy of science, innate critical thinking may lead to the clear observation that theories are based on sets of premises, and those premises are fundamentally inductive, just like non-scientific theories. Consequently, the skeptical renaissance seems return to the classical question, �Why is science the best way to answer questions and to solve problems?�

Today, scientists have attempted to resolve the infamous �problem of induction� that was first elucidated by David Hume using various techniques. Arguably the most influential has been a movement out of Vienna known as �Logical Positivism,� figure headed by Karl Popper. Popper required that all scientific theories are falsifiable, meaning there are tests that could hypothetically disprove the theory at hand. However, non-scientists are occasionally prone to adopt a form of Descartes� �Demon Hypothesis� (In which he posits that we cannot be certain that anything is true because it is possible that a demon implanted that information in our minds to sabotage us) when considering the certainty that science can produce.

From the perspective of a modern skeptic, what is the point, of taking to heart anything science tells us, if we don�t believe it to be a valid authority? We�ve all heard Mark Twain�s adage, �There are lies, damn lies, and statistics.� A student who rejects the validity of scientific research about the interaction between alcohol and acetaminophen might be less likely to avoid mixing the two chemicals. To this extent, the skeptical renaissance promotes a culture of indifference with regard to the suggestions that scientific research offers us, including suggestions about health.

Demand for Holistic Healthcare

The skeptical renaissance may also be interpreted as a rejection of orthodox medicine, often referred to as allopathic medicine, in favor of a more holistic approach to healing. As can be inferred by the current national discussion about healthcare, by most accounts, the western healthcare system is damaged and in desperate need of repair. Patients may lump all of their complaints about the treatment they receive on the system itself, whether not that format is actually the culprit. Disillusioned with long waits and poor treatment, many patients call for an overhaul of the entire medical system. Some patients hope to see the healthcare system take other things into account when treating illness, include their life circumstances and mental state. When available western medicine does not provide these requirements, some patients turn--or would like to turn--to alternative medical approaches to pursue health.

Some patients are particularly critical of the "interventionist" attitude of western medicine, feeling that doctors intervene with too many potentially unnecessary procedures and medications. An interesting facet of the alternative medicine movement is that in its own way, it is often still a fundamentally interventionalist movement. By this, I mean that it takes the stance that health is best achieved by engaging in some form of intervention, whether it is yoga, Ayurvedic tea, or acupuncture treatments. To that extent, the alternative medicine movement is not a renaissance of widespread classical ideas (besides the anachronistic beliefs it occasionally adopts), but is, as its name implies, simply an alternative to customary medical practices. For patients with unresolved allegiance to a particular medical orthodoxy,the influence of alternative medicine might further contribute to indifference with regard to allopathic approach to treatment in favor of alternative health theories.

White Noise

Finally, the most profound characteristic of the current health culture is the �white noise� of perceivable health risk. We are inundated with messages about how dangerous the world is, from skin cancer risks to pollution to diabetes. Short of living in a bubble, we cannot possibly live our lives preparing to responsibly combat every risk to the state of our health. As a result, some of us tune out the white noise into the background ambiance of our lives. Like the boy who cried wolf, the overabundance of health risk messages makes it difficult for normal people to decide which messages to take to heart and which to overlook. Most recently, the public�s mockery of the Swine Flu pandemonium is an example of an overlooking the efficacy of our public health department in curbing what could have potentially been a disastrous epidemic.

This leaves many people left to decide for themselves how evaluate available evidence and make health decisions themselves. Unfortunately, as this project has made explicit, people�s beliefs are subject to inherent bias. One famous study exposed the extent of this phenomenon. Two groups of people with different initial beliefs about the health risks of marijuana were presented with the same research about marijuana. After evaluating the evidence, each group took even more extreme positions about the health risks of the drug. The research subjects tended to see flaws in the studies whose results did not fit their initial views, and did not see any problems with the studies that supported their views. The study concluded that a biased search for information can lead to a distorted view of the evidence that appears to confirm one�s preexisting view.

In the case of personal health decisions, people may be biased to tune out health messages they do not want to hear. Students may read research about academic performance enhancement and be overly skeptical of experimental flaws if the research indicates a stance on academic performance enhancement that conflicts with a preexisting belief.

The white noise also inundates us with contradictory messages about health risks. For example, cigarette advertisements are not allowed on TV because they are seen as foreseeably influencing young people to make dangerous health decisions. However, shows like Jackass and Travis Pastrana�s Nitro Circus celebrate activities that are incredibly dangerous and put practitioners at a high risk of traumatic injury. These shows could very well influence young people to make poor health decisions that are equally as dangerous as smoking cigarettes.

Health Identity and Risk

This is all to say that it is not easy for members of our generation to adequately assess health risk. When added to the number of people who will make poor decisions anyway regardless of available health information, it is very possible that this is an incredibly dangerous time for population health. The things that made us live longer in the 20th century, such as improved sanitation and antibacterial medications, are being offset by unhealthy behaviors that lead to diabetes, strokes, and heart attacks. We have yet to see how the health of our population will be affected by new technologies including ipods, laptops, and cell phones. We can assume that at the very least, there will be a rise in hearing loss, since loud noises are the dominant reason for hearing loss in old age . Ray Kurzweil gained notoriety in 2004 for his book, Fantastic Voyage and its contention that soon humans (himself included if he can live for the next 50 years taking 3 hours of intravenous vitamin supplements a day provided by a personal hired vitamin assistant) should be able to live forever. In stark contrast and as a matter of record, I predict that the next generation of Americans will be the first generation to demonstrate lower life expectancy.

It may be difficult for individuals to even develop a concept of their own health identity. Imagine an island of 400 lb humans. Every year, the island people hold a race around the perimeter of the island. This year, one village has been training their fittest athlete to compete in the games, for she weighs 300 lbs. Relative to everyone on the island, she displays the healthiest cardiovascular system every witnessed. Unfortunately, when she travels to a neighboring island to compete in their annual race, she finds that she is considerably less fit than their average contestants, who only weigh 200 lbs.

To an extent, we all build a relativistic health identity based on our peers and surroundings. In the West, this identity has become associated with an increasing life span. Among niche communities, some behaviors may be seen as very healthy or very unhealthy depending on the constituents of that community. For example, among chain-smokers, a person who smokes five cigarettes a day may seem relatively healthy, yet among non-smokers that person would be considered very unhealthy (assuming that in both communities, excessive smoking is considered unhealthy). This culture of relativism makes it very difficult to appraise the degree of risk that any action incurs.

Yet at the end of the day, perhaps many people are really just in denial. Plenty of students regard Adderall use as illicit and dangerous; yet choose to use it anyway. It is easy to say, �it�s worth the risk� when making a decision if you do not have to suffer the consequences immediately. However, there are not many people suffering from emphysema who maintain the same sentiment about smoking as they did when they were young. Although this has always been the case about risk prediction, it is especially easy for those who engage in cost/benefit health decision-making in this generation to justify bad decisions with skeptical rationality.

One thing science is NOT good at answering is what we ought to do with the results it shows us. For now, as we open the national conversation about health care, we should take advantage of this widespread discourse and include an evaluation of the theory of "good health" itself to help influence the types of expectations and demands we ought to place on the health care system>

Footnotes

Please excuse the reader's digest poll. Perhaps if I ever modify this post for a different publication I'll use a better source of data on this question. I would like to emphasize my belief that people are more likely to deny a desire to live forever when they are healthy than when they are sick and believe their illness is curable. Patients who previously thought they'd never want to burden their families with terminal illness sometimes surprise themselves when they see how hard they cling onto the hope of life in the face of death. My experience with this phenomenon has inspired me to change my philosophy about the allocation of scare medical resources and advocate age-blind decision making. ?

Published on December 7, 2010 in Medicine