Surgery as prophylaxis

The world buzzed yesterday with the news that Angelina Jolie underwent a double mastectomy to greatly diminish her risk of breast cancer. I’ve been a fan for a long time, but she has my respect for the editorial she penned for the New York Times revealing her procedure. It’s intelligently written, explains the tests and procedures she went through, acknowledges other treatment options and choices, and thanks her loving family. It can be difficult to understand having such a dramatic procedure done with no sign of current illness, but as one woman who made the same choice put it, “If someone said your flight was 86% likely to come down, you wouldn’t get on that plane.”

With better knowledge about risk factors and a decrease in the cost of  genetic testing, an increasing number of people are proactively seeking surgery with no evidence of disease.  A presentation at the American College of Surgeons Annual Clinical Conference last year analyzed data on this trend from 2004-2009.  The number of hospitalizations related to genetic susceptibility increased 16-fold during that time, and prophylactic surgeries more than doubled. Insurance plans are increasingly covering these surgeries as a cancer risk reduction strategy based on family history, pre-disease symptoms, and/or genetic testing. This policy sheet from provider Priority Health is one example; it describes criteria not only for prophylactic mastectomy but also removal of the ovaries, stomach, uterus, or thyroid.

Jolie isn’t the only public figure in the news recently for surgery to reduce illness risk.  New Jersey governor Chris Christie revealed last week that he had undergone bariatric surgery in which a band is used to section off part of the stomach, reducing the quantity that can be eaten at one time. Though some have questioned his motive, Christie made this decision at age 50 and while morbidly obese, at increased risk for heart disease, stroke, some cancers, and concerns from joint problems to sleep disorders. Though the surgery isn’t a cure-all (I was told recently by a specialist in this area that more than 50% of the procedures now performed are revisions to previous surgeries; not because of a problem with the surgery, but to increase effectiveness for a patient who has stopped losing or started regaining weight), Christie has a good chance of dropping enough weight to make a significant difference in his risk of disease.

There are many issues to consider here and many frameworks that can be applied, but I’ve been thinking about identity. People who undergo major surgery as a risk reduction strategy will wear the scars and/or have lifestyle changes forever. Their lives are different because of a disease they feared, which becomes part of their embodied identity nonetheless. I think there must be an identity shift that precedes that, from seeing oneself as healthy to envisioning the body as vulnerable and imminently diseased.  The presentation mentioned above noted an association between surgery-seeking and level of anxiety about disease. I wonder if that anxiety marks an identity borderline, from a woman who sees herself as fine but at risk and chooses vigilance and lifestyle alterations, for example, and one who sees herself as having a disease that hasn’t yet surfaced and seeks surgery to remove tissues already considered unhealthy.

Who are the weird?

There’s a fascinating article making the rounds of various blogs this week, which does a nice job of summarizing the interesting findings of a young group of psychologists looking at cross-cultural variation in a series of games and perceptual tests that have long been assumed to measure universal human qualities.  Over and over again, they are finding that Western subjects respond in very different ways than most people to these kinds of tests; in fact, Western subjects are outliers, even though the vast majority of our data on human behavior and psychology (96% of psychology studies) is limited to the study of Western populations.

This is not exactly news to most anthropologists (or to anyone; the paper the article is discussing came out a few years ago and was widely discussed then as well), but the article does not let the discipline off the hook, accusing the anthropological stance on cultural diversity of being incoherent in that we want to maintain two incompatible claims.  On the one hand, anthropologists extol cultural relativism as a basic principle, emphasizing that cultural differences are real and significant and need to be respected.  On the other, undergraduates come away from an anthropology class with the sense that we are also all underlyingly the same.

This strikes me as a fair critique to a limited extent, but the quandary of the anthropologist is less severe than that of those social sciences (psychology, economics) that want to assert the existence of an analytically accessible mind underlying and separable from cultural variables.  I think many of these kinds of social scientists will come away from the article shaken, but not despairing; maybe, they will reason, you have to try for cross-cultural representativeness for things like game theory, but surely not for things further along the biological end of the biocultural spectrum.  And yet we know from our course readings that this is not true either: we have seen that what seem like very biological processes, from so-called African “precocity” (Gottlieb) to “normal” menstruation patterns (Strassmann), are very different for most of the world than for the Westerners who have long been presumed to be typical.

The always incisive neuroanthropology blog has done a great job of giving an overview of the review article, as well as pointing out some of the problems inherent in the neologism WEIRD (Western, Educated, Industrialized, Rich, and Democratic), despite its catchiness.

Perils of quantification

New Year’s Resolution season is upon us again and with it, many of us will be setting goals that are tied to our behavior or self-improvement.  With a goal there should be a way to measure progress, and watching a number change can provide potent motivation.

That’s part of the basis for the quantified self movement, consisting of people who use self-tracking to collect data about how their bodies and minds work (we’ll debate duality another time), often for the purpose of understanding and optimization  This is introspection and self-disclosure taken to a new level.  Some use an artistic approach, like Buster Benson, who – among many other things – takes a picture of himself at the same time each day.  J. Paul Neeley, seen in this video from the Mayo Clinic Center for Innovation Transform 2012 conference, has put a lot of thought into optimizing his happiness based on observations from self-tracking.  Others take a hardcore medical approach, tracking weight, heart rate, respiration, blood pressure, sleep hours, caloric intake and balance, and other objective numbers.

Many of the methods used by quantified self practitioners could be found in a social science textbook, but they are applied to a sample size of one.  Some of the findings apply no further.  Other data, shared and aggregated, could lead to discoveries that improve the lives of many.  I’ve seen the movement described as little more than a herd of narcissists, but my opinion is that it’s a display of millennial attitudes of curiosity, openness, introspection, and embrace of technology (which are not limited to an age range, but worldview).  Perhaps it’s microanthropology or micropsychology as well.

That said, I was struck by a short essay by Jeff Wise on the last page of the November 2012 issue of Red Bulletin magazine (produced by the energy drink company yet a fun, free read; see their website).  His piece, entitled “The Measure of a Man”  begins by talking about the difference between subjective methods of self-awareness, such as “I have trouble fitting into my clothes” and objective ones like “I weigh 233 pounds.”  Seeing the number on the scale go down to 232 provides immediate external positive reinforcement and a sense of control.  It’s strong motivation to keep moving that number in the preferred direction.

However, Wise points to the danger of focusing on a particular metric.  He compares it to the use of a district-wide test to measure student performance.  “The first year… their scores offer a rough measure of the overall quality of their education.  But in subsequent years, those scores will increasingly measure something else: Teachers’ ability to prepare their pupils for that particular exam.”  Applied to tracking weight, he warns that “what you measure becomes what you do, and what you do becomes who you are,” with the potential for eating disorders, substance abuse or neglecting other aspects of good health.

In reading blogs of the quantified self crowd, I’ve frequently seen this in confessions that the trackers have changed behavior to make one particular metric “look better”, often at the expense of others.  Even in our introspective attempts to understand human nature, we display it.

Can two people share a mind?

This article is mind-blowing: there’s no hard proof, but a lot of intriguing evidence that two little girls are in some way sharing each other’s consciousness.

Born with an extremely rare (the rarest- there are no other cases in medical history) form of conjunction at the head (craniopagus), Krista and Tatiana Hogan seem to share mental and physical experience through a thalamic bridge.  Their neurosurgeon hypothesizes that when either of the girl’s bodies experiences sensory input, the signal passes to both brains.

It’s hard not to speculate on the big questions this medical anomaly engenders: on the nature of the self, and on the nature of consciousness.  And these big philosophical questions are ones that Krista and Tatiana have to negotiate continually at a very practical level: what pronoun should the girls use to refer to themselves, and what does it mean?  What if their connectivity extends beyond basic sensory input, to higher-order thoughts and preferences?  There are some good links in the article to philosophers and neurobiologists who had been thinking about these kinds of problems before the extraordinary case of Krista and Tatiana.