It wasn't long ago that
the quest for self-knowledge meant analyzing the psyche as opposed
to, say, the colon. But that was before Katie Couric showed us
hers on national TV. Now, for those who can afford it, knowing
thyself often means knowing, quite literally, the stuff of which
you are made. It means availing yourself of the newest and most
intrusive technology to find out virtually everything there is
to know about your physical being.
Consider the flourishing ritual known as the executive physical,
a perk that about half of all large American companies offer their
top managers each year, though many doctors say there is no medical
benefit to such frequent and comprehensive exams. Recipients of
this largess are dispatched to "executive health programs" at
deluxe venues like the David Drew Clinic in Chevy Chase, Md.,
where they spend a day submitting to "the latest high-tech medical
approaches in the surveillance of occult illness, including genetic
testing, body imaging and state-of-the-art disease markers."
Such thorough plumbings of your inner space cost around $2,700.
Fortunately, the rest of us can undergo the downmarket versions
of aggressive screening. Preventive CAT scans -- total body imaging
of healthy people, at only $600 or so -- are becoming increasingly
popular, even though most doctors consider them ill advised. Meanwhile,
new companies like HealthScreen America offer consumers the chance
to order up their own diagnostic exams -- for everything from
prostate cancer to stroke risk -- get the tests done at their
local mall, then download the results from the Internet. Such
direct-to-consumer exams are sure to multiply in the future, and
it won't matter if their medical value remains contested. They're
a hypochondriac's dream -- the means to investigate every little
bleep of a symptom, without ever being brought to your senses
by an actual doctor.
Would-be Howard Hugheses, your Shangri-La awaits. Imagine home
CAT scans in the privacy of your own marble bathroom. Automatic
urine analysis with every flush. Computerized life-expectancy
projections updated after each meal. Home exercise equipment that
transmits your blood pressure and heart-rate readings directly
to a lab (and maybe to your insurance company too) every time
you break a sweat. Bedside spirometers for measuring lung capacity
before, during and after sex.
Who will want this stuff? There will be people who see a value
in knowing exactly what their lipid profile says about them, and
people who, more fatalistically, do not. And this division will
likely map onto pre-existing conditions of class. Those who want
to know will tend to be the wealthy and educated, people who assume
that money and information well deployed can save them from almost
anything. On the other hand, in a recent study involving family
members at risk for a hereditary colon cancer, 60 percent did
not want to know the results of a test that would reveal whether
they had the relevant DNA mutation. The less formal education
they had, the less likely they were to want to know.
Moreover, these new screening opportunities for the worried well
will cost the rest of us something, depleting the resources available
for more practical preventive health measures -- smoking cessation
or weight-loss programs, for example. "Somebody who's 25 and thinks:
Hey, what's the problem? I'm paying for my own mammogram, sets
into motion a whole chain of things," says Dennis Fryback, a professor
of preventive medicine at the University of Wisconsin. "There
will be additional tests, biopsies. Insurance pays for those,
which raises everybody else's premium. And we always get many
more false positives than true ones."
There are screenings, of course, whose preventive health benefits
are known and proven -- TB tests, mammograms for women over 50,
pap smears. But there are others -- mammograms for men -- that
are dubious because while they could benefit somebody (a few men
do get breast cancer) they would do so only at tremendous cost
in both dollars and anxiety to a large population of extremely
unlikely victims. And there are still others -- full-body CAT
scans, large-scale testing for prostate cancer -- that are dubious
because what they turn up may be a very slow-growing tumor or
an "indolent" disease that would never have caused a problem if
the patient hadn't known about it. Only now that he does know,
he may have unnecessary surgery (which carries its own risks).
Or he may move through life burdened by the sense that he is a
future patient, an illness waiting to happen.
The truth is, it is not always easy to put such portentous knowledge
to rational use. Consider this cautionary tale. Some years ago,
Sweden established an experimental program in which about 200,000
newborns were screened for a recessive genetic condition that
would predispose them to emphysema as adults. Since exposure to
cigarette smoke, dusty environments and the like would increase
the chances of contracting the disease, doctors anticipated that
families whose children had this genetic predisposition could
change their lifestyles accordingly. Instead, the whole program
had to be canceled because families experienced such high levels
of emotional disturbance. Parents reported that they couldn't
help thinking of their affected children as "different"; many
of them said that their anxiety about the disease lying in wait
led them to smoke more, not less. In the end, maybe there is such
a thing as too much information -- a diagnostic dystopia in which
an anxious few of us are privileged to know too much about what
we are made of, and too little about what it means.
Copyright 2000, The New York Times
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