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A bad feeling

January 23, 2011 5 comments

According to famed bioethicist Leon Kass, we should listen to “the wisdom of repugnance.

Revulsion is not an argument; and some of yesterday’s repugnances are today calmly accepted — though, one must add, not always for the better. […] In crucial cases, however, repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it.

If I held myself to such high standards, I would tell you that I find the thrust of what I see as mainline bioethical thought to be “icky,” and from there res ipsa loquitur. However, I’d like to think that my distaste has more than mere “revulsion” behind it, and as such the matter is not so easily disposed of.

In the “standard” ethics and professionalism lectures, medical students are taught that medical ethics rest on three foundational pillars: non-maleficence (“do no harm”); beneficence (“do what’s best for your patient”); and autonomy (“act in accordance with your patient’s wishes”).

Who decides what’s best for the patient, or what constitutes harm? Logically, it should be the patient! When the stakes are high, so too should be the barriers for a physician to substitute his or her goals and values for the patient’s.

SUMS has a thriving medical ethics program, and we’ve had the opportunity to hear clinicians and medical ethicists from SUMS and from farther afield talk about ethical conundrums they’ve seen on the wards. Every presentation has shared one feature, without fail: it’s only an ethical conundrum (usually meriting a call to the bioethics committee) when the physician doesn’t agree with a patient’s choice, and has been unable to successfully use persuasion or coercion to change the patient’s mind.

This seems like a trivial observation at first. After all, why call the ethics committee to adjudicate a matter where the physician and patient are in perfect agreement (aside from rarer edge cases where this happens, usually involving experimental procedures)? It makes perfect sense!

What this means though, is that the medical ethicist has become the person to provide cover for a physician to override the patient’s autonomy. By virtue of selection bias in the cases they are asked to adjudicate, and the ever-present threat of regulatory capture, the role of “medical ethics” runs the risk of devolving into Paternalism 2.0. “We know what’s best for you, and if you don’t believe us, we’ll make you.” What’s more, when the medical ethicist is nothing more than the cudgel with which the physician forces his goals onto his patient, what claim does the ethicist then have to support his monopoly on decision-making in this sphere?

Admittedly, this image of medical ethics is a caricature. But to see the danger that lies in store, look no further than their cousins: the bioethicists.

At every turn I can think of, bioethics has established itself as the true “Ideology of ‘No.'” Whether dealing with BRCA gene testing for breast cancer susceptibility, assisted reproduction technologies, APOE4 screening for Alzheimer’s susceptibility, or “cosmetic” fetal ultrasound, mainstream bioethical opinion always seems to come down on the side of denying information to patients. Hardly the patient-empowering mindset that marked the field’s nascent days.

So why has the medical ethics / bioethics enterprise come to undervalue patient autonomy so extensively? I offer two preliminary hypotheses.

First is the fact that medical ethics and bioethics are situated in an academic-institutional environment that usually leans left-liberal (Progressive). Whether the institution makes the people, or the people make the institution, it comes out to the same thing: the setting is one that inculcates a predilection for top-down technocratic control. I think that this assessment is valid, regardless of what you think of the merits of different political philosophies.

The second one is, in my mind, more interesting. Public choice theory reminds us that bureaucrats, leaders, institutions, and their people do not exist in a world devoid of incentives and personal agendas. As an ethicist, when you say “no,” you entrench the need for your services… there needs to be someone with the authority to say “yes,” and what better way to establish your authority then by saying “no?” When you posit increasingly more complex models for evaluating ethical dilemmas — “autonomy, beneficence, and non-maleficence” just don’t cut it — you create an institutional need for someone with expertise in dealing with these complex rules to act as interpreter, and thereby increase your own power and prestige. Giving full weight to patient autonomy would undermine the need for your services.

This isn’t to say that ethicists make decisions with an explicit eye to entrenching their influence in the medical setting. It is, however, a reminder that we should always be asking ourselves: quis custodiet ipsos custodes? Who watches the watchers?

That, and the “wisdom” of repugnance is only as valid as the reasoning that supports it. Having “a bad feeling” about something doesn’t cut it when lives are on the line.

Model Marketing (and New Hampshire’s $4,300 cheek swabs)

December 17, 2010 Leave a comment

I have been asked many times to register for bone marrow donor registries.  I’m told that there are severe shortages of potential donors from my ethnic group, and that ethnicity correlates with the probability of successful match.  I’ve been solicited again and again over email listservs in college and here at medical school, reminded of the life-saving potential of a simple cheek swab (and subsequent marrow harvesting, if matched).  One particularly aggressive college classmate told the assembled masses that ”choosing not to donate is essentially deciding to let somebody die. And, yes, you are responsible for that.”

Strong words, those.

However, I have never been asked to register as a bone marrow donor by ”flirtatious models in heels, short skirts, and lab coats.”  Not that I would have found that approach particularly persuasive.

What might seem, at first glance, like an innovative approach taken from the playbook of marketing professionals, has instead been depicted as a nefarious attempt to scam insurers out of around $4000 per cheek swab tested.

“They got people to do this without telling them it could be a charge of $4,300 against their insurance,” he said.

New Hampshire passed a law in 2006 requiring insurers to pay for tissue-typing tests for potential bone marrow donors. But at the time, Mr. Boffetti said, proponents told lawmakers that each test would cost $100 or less.

How absurd!  This group should be lauded for their efforts to increase the pool of potential bone marrow donors!  That non-profits and charities are adopting the for-profit sector’s successful marketing techniques is a sign of progress, not nefarious intent!

Here’s a thought for New Hampshire’s ”senior assistant attorney general:”  there would be no need to investigate and vilify this group for…. I don’t even know exactly.  The article doesn’t imply they’ve done anything illegal or unethical.  They seem to have simply billed insurers as the law allows them to.

This is one of those problems that seems like it could only be caused by idiotic regulation.  Getting a cheek swab and tested for bone marrow donor registration is clearly not a risk against which one needs to be insured.  It’s an elective procedure that has absolutely zero health benefit for the insured party.  New Hampshire’s legislators, in their infinite wisdom, decided to mandate coverage anyways.

And somehow the Times portrays the models as the most unseemly part of this saga.

Cavalcade of Risk #112: The Cavalcade Gets Schooled

August 24, 2010 5 comments

It truly is an honour to have been asked to host the 112th edition of the Cavalcade of Risk blog carnival!  After all, I am but a lowly, economics-trained fledgling first-year medical student who has been blogging here for less than six months (still considerably longer than my time as a med student to date!) and who still has the occasional blog formatting issue or two.

The excitement surrounding the start of medical school is far from wearing off; as a result of that continued excitement, I decided to take the Cavalcade with me to classes.  Remember:  everything you read here is fair game for the final (and the licensing exam)!

Cavalcade of Risk #112:  Medical School Edition

Behaviour and the Brain

The workers' comp adjuster described this case as "a major headache."

Brains are important.  There are several pre-clinical courses that deal with them, and not just because the subject has a starring role in the licensing exam (and on the menu at the Bistro Zombie).  The brain is the seat of our behaviour, emotion, rational capacity, and risk assessment capability.  Even with this fascinating organ working at full tilt, dealing with risk rationally can be difficult.  Of course, we humans are far from perfectly rational, which makes for even greater challenges.  GrrlScientist links to a TED talk in which a researcher tries to gain insight into the root of human irrationality by examining decision-making in monkeys.  [CONGRESS JOKE DELETED]

Regulatory Compliance

Perhaps the most fun part of medical school orientation is the parade of sessions required by law, by the university, or by the medical school, for little other purpose than to be able to check off a box and say “the students are aware of the policy.”

If legislation had animal mascots, you would be looking at the HIPAA Hippo and the Son of HIPAA Hippo HIPAA Hippo

Of course, some of this compliance information is actually high-stakes.  For instance, this year’s HIPAA training session included a portion on medical identity theft red flags.  However, as well-trained and as eagle-eyed as the medical students are, you are your best first line of defence when it comes to preventing medical identity theft.  Ryan from CashMoneyLife has a post that explains how patients can both detect and protect themselves from medical identity theft.

Physiology

The Physiology of the Medical Student

“Phys” is all about how stuff works.  The typical first-year physiology course is a detailed overview of how the body works under normal conditions.  It’s easy to take for granted the complexity and intricacy of the processes that keep us alive, in part because most of the time, it all works without any effort on our part (knock on wood).

Protecting the normal physiology of business partnerships is the subject of the next post.  Jacob at My Personal Finance Journey explains how a combination of buy-sell agreements and properly-structured life insurance contracts can be used to make small business partnership succession go much more smoothly with much less effort at a stage where there will already be so much in flux.

Histology

The upperclassmen tell me that we look at a lot of slides in histology. As you can see, I'm trying to get a head start.

Histology, the study of tissues, typically involves lots of staining, sketching, and microscopy.  While advances in technology means that some slides are digitized for ease of review, there’s still plenty of opportunity to get your hands dirty with “the real deal,” just like the Disease Management Care Blog did with his submission to this week’s Cavalcade.  Dr. Jaan Sidorov has found the National Association of Insurance Commissioner’s “Blank” proposal defining the medical-loss ratio, stained it, and put it under the digital microscope for all to view.

Pharmacology

Is it just me, or do four of these look like they're glitter-filled?

I’ve always been impressed by the ability of nearly every physician I know to rattle off drug names (and their indications, side effects, etc.) with seemingly perfect, instantaneous recall.  I’d imagine that the months-long pharmacology course in year 2 has something to do with that.  “Better living through chemistry” can be tricky to achieve if you don’t know your chemicals.

Jason Shafrin, the Healthcare Economist, describes one set of efforts to improve the benefits of pharmacological therapy by involving pharmacists more directly with the patient’s medication therapy management.

Pathology

Not to be confused with "path-ology," a course taught at schools of engineering and urban planning.

“Path” examines how the body’s structures respond to a variety of stimuli, usually bad ones.  It seeks to answer the questions “what’s going on here?  What’s wrong?  What do these cells do when we [injure/mutate/slander] them?”  In this vein, the ever-intrepid InsureBloggers emerge from their basement labs to look at one state’s new PPACA-created Pre-existing Condition Insurance Pool, and provide a concise and focused overview of its pathologies.

Anatomy

I’m fortunate to be able to use so much of the material from my undergraduate vertebrate anatomy class to review terms for medical school anatomy.  Despite the fact that, in college, we worked on cows and cats instead of humans, the similarities between the vertebrates are such that a comparative approach to anatomy can yield great dividends.  For instance, courtesy of National Geographic TV, I know of a whale anatomist who works out of a human medical school in New York City.

First-year anatomy: a whale of a good time? Or the course that will have you sitting in lab all sad and blubbering?

Joel, our next poster, uses the techniques of comparative insurance anatomy to arrive at this tongue-in-cheek “Plea For Car Insurance Reform.”  As with the vertebrates, insights from one area of the insurance world may be able to tell you something about the others.

Biostatistics and Epidemiology

The Notwithstanding Blog would like to remind all visitors to wash their hands and observe universal precautions during their visit

Biostats teaches medical students how to use quantitative tools at a basic level.  Being able to critically evaluate new biomedical research is a crucial tool for those of us entering medicine at this time of seemingly-exponential change.  Epidemiology more broadly examines health status and disease in the aggregate, including surveillance of epidemics and monitoring of health trends.  Careful use of the tools of these fields can allow one to make reasonable predictions about the future of wellness trends and epidemics, or, if you’re Louise of Colorado Health Insurance Insider, the future of PPACA-grandfathered insurance plans.

Extracurriculars

The range of extra-curricular activities at SUMS (Sorta Urban Med School) seems nearly endless.  There are running clubs, research opportunities, student government positions, specialty interest groups… the list goes on.  However, one set of time-honoured activities among medical students is health outreach and education within the local community.  Many medical schools are located in or near areas in which there are major problems with access to healthcare and accurate health information; students can and do rise to the challenge of filling those gaps as best as they can.

These outreach projects can range in tone from the humour-filled to the gravely serious.  Julie Ferguson at Workers’ Comp Insider shares a feel-good breast cancer awareness video, along with some other chuckle-inducing medical parody videos.  David Williams, host of Cavalcade of Risk #113 in two weeks, posts a guest piece about the lies and dangers of so-called “pro-ana” websites.

Material unrelated to the course that nevertheless shows up on the final because it’s the professor’s niche research interest

"Syllabus? What syllabus?"

One of the risks of starting medical school, with its concomitant classes and extra-curricular activities, is that it will affect your blogging output.  Nonetheless, I plan to stick around.  I invite all of you CoR readers to poke around the rest of this site.  If you like what you see (and even if you don’t), I’d love nothing better than to have you stick around with me!

***

Cavalcade of Risk #113 will be hosted at the Health Business Blog.

Around the Mediverse: July 8, 2010

July 8, 2010 3 comments

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • Some questions have emerged about Supreme Court nominee Elena Kagan.  Reason asks if she would ban books.  Bloggers at the Volokh Conspiracy touch on what is arguably Kagan’s political manipulation of a medical specialty society’s statement on abortion.  It should be said that the American College of Obstetrics and Gynecology comes out looking worse than the nominee.
  • Though the response to the Deepwater Horizon spill has arguably been insufficiently aggressive, here are two commentators who argue that children should be taught to better express and receive aggression.
  • What is a “scientific consensus?”  Reason’s Ronald Bailey takes on this issue.  Along the way, we stumble onto this gem of a web page explaining the relationship between animal models of carcinogenic toxicity and the actual exposure of humans to those substances.  Much more non-technical than I made it sound.  Do give it a read if only to attenuate your own “cancer panic” over some of those chemicals.
  • David Williams at the Health Business Blog reminds everyone that hospital visits should be BYOMD.
  • Two recent guest posts at KevinMD point out that the concept of the patient-centered medical home is probably way overhyped, given the current evidence “for” it.

The UCSF-Altria imbroglio

July 2, 2010 1 comment

As the New York Times, its Prescriptions blog, and the San Francisco Chronicle have been reporting, there’s been a scandal of slightly more-than-minor size involving the UCSF Chancellor’s stock holdings.  Dr. Susan Desmond-Hellmann — the oncologist at the head of UCSF’ — disclosed shareholdings in the area of $100,000 in Altria, the company formerly known as Phillip Morris that makes most of its money from tobacco-related products.  Since that disclosure, followed promptly by divestment, Dr. Desmond-Hellmann’s holdings in health products/pharmaceutical companies and fast food companies — this time to the tune of millions of dollars — have come to light.  The investments were apparently made by a third-party financial advisor without her knowledge, and this advisor has since been instructed to purge her shareholdings in alcohol, tobacco, and firearms manufacturers.

Reading these articles prompted me to consider one of my earliest posts here, in which I argued that there is nothing unethical, unseemly, or untoward about life/health insurance companies holding shares in fast food companies.  Does the same argument apply to Dr. Desmond-Hellmann’s holdings?

Yes and no.

In my mind, the most problematic of her stocks are the pharmaceutical and health products companies.  These firms are probably vendors or research sponsors at UCSF, or have the potential to be.  The Chancellor’s shareholdings in these firms are substantial, and the potential for a conflict of interest is definitely present.  As one of the ethicists quoted by the Chronicle points out, recusal from decisions that would trigger this conflict may be all that is required, but continuing to hold the shares certainly creates the appearance of impropriety.  While some have pointed out that physician-industry relationships aren’t always eeevvvilll, as others would have us believe, there is a difference between productive collaboration of the sort Dr. Rich discusses and passive shareholding of the sort at question here.

I personally find her other shareholdings to be less objectionable.  Alcohol, firearms, soft drinks, and fast food are all legal products that can be used or abused, depending on who is doing the ab/using.  I see nothing intrinsically “evil” about them that should force medical leaders to steer clear.  Many of these firms (McDonalds, Pepsi, etc.) are also components of major equity indices, and as such may well have been chosen for that reason.  It’s highly unlikely that they will be directly involved with UCSF as vendors, donors, or sponsors, though I could be wrong about this.  Tobacco, however, doesn’t pass the smell test with me, especially not when we’re discussing an oncologist.  Arguably, it’s the only one of the products in question that is inescapably harmful regardless of how it’s used.  Of course, I would be remiss if I didn’t point out that there are lots of anti-smoking groups out there who have let their love for tax revenue outweigh their desire to reduce smoking.  This doesn’t make Dr. Desmond-Hellmann’s Altria holdings more palatable, in my view.  It just places them in the context of “how worse could it be/what company is she in.”

There is a growing obsession with rooting out conflicts of interest in healthcare, often under the rubric of reducing “waste and fraud.”  Much of this is a good thing, though as people like Dr. Rich point out, this obsession comes with a risk of harmful side effects.  More and more attention seems to be paid to “who owns which shares.”  Given that companies like McDonalds, Pepsi, and Altria are major blue-chip companies that are components of the DJIA/S&P 500 — thus likely to be held by many people and institutions — and targets for public health activists, it will be interesting to see how this plays out in the future, and where the line will be drawn for medical professionals who want to be perceived as “ethical investors.”

Around the Mediverse: May 13, 2010

May 13, 2010 Leave a comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • Unconfirmed:  15th century world maps labeled the location of what would later be called “America” with the warning “Here There Be Litigiousness.”  WhiteCoat links to an AMA report that looks at key differences between the US medmal system and those of other developed countries, with an eye to what differences may or may not translate into improvement in the US.  Great Z’s brings us the details of a case in which drugmakers were found liable for Hep C contracted by patients whose physician reused needles when administering the drug.  A guest post at KevinMD gives tips on how to survive a deposition during a medical malpractice case.  Edwin Leap reminds us that a large part of being a physician is the ultimate accountability for patient care… and that this accountability has to be compensated.
  • Jason Shafrin at Healthcare Economist runs down the math of running into a terrorist.  Bottom line:  don’t sweat it.
  • Greece and the Euro continue to be in the news:  what does it mean for us on this side of the pond?  Greg Mankiw links to an article that claims that crises such as that in Greece show that we cannot have democracy, nation-states, and globalization together.  Reason talks debt, deficit, inflation, and the future of America’s fiscal situation.  On a lighter note, Mark Perry shares a video showing what you can learn about economic communities if you literally follow the money.
  • The Health Affairs blog presents a proposal to “Reinvent The Primary Care Workweek.”  Importantly, they realize that the quality of the job is at least as important as payment in getting more students to choose primary care fields.  Of course, a patient load that small means that you need more people to join the ranks pretty quickly after implementing the model.  Seems like a good idea, but we’ll see what happens.
  • Finally for this week, Scott Greenfield brings us a lengthy, compelling, and disturbing story from the Village Voice that takes an inside look into incentives and operations at the patrol level in New York City’s 81st precinct.  From a political/legal/libertarian point of view, it’s frightening.  If you insist on putting a health policy lens on it, call it what happens when you implement the ultimate pay-for-performance system alongside the ultimate EMR.  Enjoy…

Around the Mediverse: May 7, 2010

May 8, 2010 Leave a comment

Fun tidbits, health-related and otherwise, from around the ‘tubes:

  • I like the idea of “concierge” medicine, even though there are many vocal opponents of the concept.  I reject their argument that it is necessarily something that will limit itself to the richest and best-off in society.  I present to you PartnerMD and Qliance.  Much more has been written on Qliance here, here, and here.
  • The Volokh Conspiracy had a series of eloquent posts on Harvard Law School’s Emailgate, all to be found here.
  • Economists like to say that their field is a science.  There’s some legitimate disagreement on that point.  There really shouldn’t be any such debate about the nature of such things as homeopathy and the anti-vaccine movement.  It’s unfortunate that there still is.  Megan McArdle discusses homeopathic WMDs in the first link, and Science-Based Medicine answers all of your anti-vaccine loaded questions in the second.
  • There’s been a lot of anger directed at Wall Street recently.  Someone there decided to direct a little bit back to the rest of us.  Enjoy!
  • Maggie Mahar at Health Beat Blog argues that our society is suffering from “cancerphobia” and an accompanying “epidemic of diagnosis.”  If I weren’t already persuaded of these points, this would have convinced me.
  • There’s always a lot of talk about Medicare and Medicaid, but this past week brought us talk from CMS.  Health Affairs conducted a roundtable discussion with past heads of CMS.  The transcript is fascinating; the conversation touches on political and funding dynamics within the agency and department, the mechanics of anti-fraud activities, the implementation of reform, how physicians were ignored, and how Don Berwick will fit within the agency.  From the CMS of the present, we get the Chief Actuary’s report on the PPACA, summarized by John Goodman.  It really does not look pretty.
  • InsureBlog discusses the travails of a health insurer offering a so-called 100% HSA/HDHP.  I have to wonder, from an economics point of view, whether people will be more judicious in their spending even though the money originally came from someone else (i.e. their HSA was topped up for them).  Endowment effects and whatnot.  If that is the case, and if the insurer can get the premium right to reflect the relative injudiciousness relative to “true” out-of-pocket spending, then this model could be a very real alternative to the current mainstream of first-dollar medical coverage.
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