04/05/2011 08:23 am ET Updated Jun 05, 2011

Initial Reactions to the Calorie Count Law

You have doubtless heard that the FDA is formally proposing regulations that would require the posting of calories in many venues where people meet food. You have also doubtless heard the news, and the consequent lamentations, that cinemas have been exempted. No calories on display for that barrel of buttered popcorn!

So, let's deal directly with this exemption and decide if it makes sense by asking the obvious question: should medical marijuana be legal everywhere, or not?

If that doesn't seem the obvious question, or a direct approach to the popcorn-calorie-conundrum, buckle up! We'll get there.

You likely had a knee-jerk reaction to the marijuana question. You may feel strongly that marijuana should absolutely be available for medical use. You may feel just as strongly that the idea is outrageous -- it's an illegal drug, after all. Or, you may feel you don't know enough about medical marijuana to decide.

But I think the best response to the question is another question, a deeper question, a question that gets at the principles -- the first principles -- that most reasonable people would agree should decide the matter: on what basis is any substance approved, or disapproved for medical use?

Let's at least agree that trying to answer this about a drug, and never bothering to answer it about all drugs, is inordinately inefficient. It means starting the same debate from scratch every time. Truly silly at best -- a formula for inconsistent idiocy at worst.

So, on what basis should any drug be approved, or disapproved?

We might think a drug should be disapproved if it's dangerous. But that's clearly not so; drugs far more dangerous than marijuana are used in medicine all the time. A few that spring immediately to mind include nitroprusside, Ketamine, Coumadin, and haloperidol.

Perhaps a drug should be disapproved if it's addictive? That's clearly not the case either, since vastly more addictive drugs than marijuana are in routine use -- among them the benzodiazepine class of sedatives, home to Valium, that are among the very few habit --forming drugs from which withdrawal can be lethal. But then again, alcohol is also potentially habit-forming, and withdrawal can be lethal -- and not only is it approved for use, but no prescription is required. And while on the topic, plain old tobacco is more addictive than cannabis.

Well, all right -- perhaps a drug should be disapproved if ... it's already disapproved! Perhaps we should simply hold the line against medical use of substances that are already illegal. That would be enough to dispatch marijuana.

But, it would also be enough to dispatch cocaine and heroin, and here -- I've got bad news. Cocaine is an approved drug, on hand in virtually every emergency department in the country. It is used, among other things, to control epistaxis -- the medial term for severe nose bleeds. During my years as an ER doc, I made use of it on a number of occasions. We would soak cotton in a cocaine solution, and into the patient's nose it would go.

As for heroin, it's not legal per se -- but Dilaudid is. This is a synthetic opiate pain killer that is, in essence, heroin on steroids. It is many times more potent than heroin or morphine in its narcotic effects.

We could, I think, come up with sound criteria to guide decisions regarding all drugs. They would include such things as: a clear need; clear results of testing; a favorable benefit/risk ratio when used as intended; and so on. For what it's worth, medical marijuana almost certainly passes through any such filter -- but that's a topic for another time.

What about medically-assisted dying? This is another emotive, provocative topic prone to evoke reflexive answers, but not a lot of reflection. If the goal of medical treatment is to extend life at all costs, the topic is clearly taboo. But then, the right question is: what is the goal of medical treatment?

Personally, I think medical treatment is about the patient. I think it serves the patient of sound mind, and the family of sound heart. Admittedly, soundness of mind and heart can at times be hard to judge, but more often than not we can make the call. But this, too, is a debate for another day. My point now is simply that judgments about medically-assisted dying in the absence of judgments about the fundamental objectives of medical care are cart before horse, and tail wagging the dog.

Perhaps we want to oppose all societal actions that aid and abet misguided, or objectionable behavior? That is a customary objection to so-called "harm reduction" strategies, such as needle exchange programs for IV drug users. Such programs have been shown, decisively, to reduce HIV transmission without increasing drug use -- but there is a prevailing objection on principle.

But is it a "first" principle, applied consistently? I dare say not! Seat belts and air bags prevent injuries and deaths from car crashes that overwhelmingly would not occur in the first place if people didn't drive while impaired, drive while distracted, or exceed the speed limit. So, don't seat belts and air bags "aid and abet" speeding, driving under the influence, and so on? I leave you to chew on it.

And with that chewing, we return, at last, to popcorn. Should cinemas be obligated to post the calorie counts of popcorn, and candy?

The better question, of course, is: on what basis should calories ever be posted? Presumably, so that people prone to epidemic obesity can better gauge daily intake, and in the hope that such knowledge is power. The first principle here would be that consumers should get relevant information about what they are consuming to make informed decisions. Calorie content of foods is analogous to MPG listings for cars. Why shouldn't we know? On this basis, it seems hard to justify the cinema carve-out.

Perhaps the carve-out can be justified because most people don't go to a cinema every day. But then most restaurants could make the same claim. Perhaps the fact that the movie is the main attraction and the popcorn a secondary consideration justifies the exemption. But that would invite exemptions for all "side dishes." It might also encourage McDonald's to install screens in all franchises and show movies continuously -- and then argue that the food is an afterthought.

I have made the case before that my enthusiasm for calorie posting is limited, because people don't eat to fill a calorie quota -- we eat to feel satisfied. I favor labeling that better indicates which foods are more nutritious overall, and likely to provide satisfaction with fewer calories. That said, I think calorie posting is better than no posting at all -- and see no reasonable reason for cinemas to be excluded.

The cinema exemption in the current FDA proposal is of course much about large sums of money changing hands, and the work of lobbyists. But it also reflects our general, societal tendency to debate the exception without establishing any consistent rules. To debate the case, while neglecting the context.

Stated differently, a Swiss-cheese pattern of public policies is what ensues when a society gets what should be food for thought, and swallows without pausing to chew, or ... think.

Dr. David L. Katz;