A bad feeling

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.

Defensive Medicine 101… it starts now

Over the past few years I’ve seen many exhortations (such as this one) to be aware of the “hidden/shadow/unofficial/cultural curriculum” of medical school. The “hidden curriculum” is that part of training that imbues us freshly-minted medical students with the often-unspoken values, norms, stereotypes (surgeon jokes, anyone?), and attitudes common to the profession.  Most often, this “hidden curriculum” is said to be imparted unintentionally by professors and clinical role models.

Sometimes, however, there’s nothing hidden or unintentional about it.

Our recently-started anatomy class actually begins with a couple of weeks of embryology.  Here’s one of the questions from the textbook, and its answer.  To be fair, the question itself wasn’t assigned, but rather the chapter in which it was located.

Question:  “A 22-year-old woman who complained of a severe “chest cold” was sent for a radiograph of her thorax.  Is it advisable to examine a healthy female’s chest radiographically during the last week of her menstrual cycle?  Are birth defects likely to develop in her conceptus if she happens to be pregnant?”

Answer:  “Yes, a chest radiograph could be taken because the patient’s uterus and ovaries are not directly in the x-ray beam.  The only radiation that the ovaries receive would be a negligible, scattered amount.  Furthermore, this small amount of radiation would be highly unlikely to damage the products of conception if the patient happened to be pregnant.  Most physicians, however, would defer the radiographic examination of the thorax if at all possible, because if the woman had an abnormal child, she might sue the physician, claiming that the x-rays produced the abnormality.  A jury may not accept the scientific evidence of the nonteratogenicity [doesn’t cause birth defects –NWS] of low-dose radiation.” [emphasis added]

There you have it.  Our first explicit lesson in defensive medicine before we even get near the cadavers in anatomy class.  Some things you just can’t make up.

***

I hear the answer to that question in the next edition will include a helpful reminder to make sure to run the radiograph order by the patient’s insurer’s radiology management service first.

Around the Mediverse: July 8, 2010

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

• OpenTable for physicians?  It does exist, apparently.  Be sure to click the link for HelloHealth to find out how that firm is bringing the power of the Internet to enhance patient care.

• As debates about research enter the public consciousness more and more often these days, Megan McArdle gives us a timely reminder of what “peer review” of publications means, and more importantly, what it doesn’t mean.  In a similar vein, Dr. Rich tries to get at the real reason for some of the outcry directed at the results of the recent JUPITER trial (statins for primary prevention in healthy adults).
  

• 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.

• New York State voted to outlaw short-term housing rentals, dealing a blow to those seeking cheap Manhattan accommodations.  Prior to the vote, this situation prompted a Reason blogger to note wryly that owning property seems to be “a mug’s game.”  Relatedly, one of his colleagues argues that property rights have more importance than is often ascribed to them.

• How the response to the Gulf spill has been hampered by protectionism and inflexible environmental regulation:  the saga of the skimming Dutchmen.

• 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.

• Greg Mankiw asks what will happen to markets for life insurance and annuities given new advances in genetic testing and identification of markers for longevity.  Genetic discrimination?  An adverse selection death spiral?  Or something in between?

• As befits someone with an economics degree and a medical school acceptance agreement, I want to showcase some recent commentary on doctors and dollars.  A contrarian voice at Slate argues that drug companies should be allowed to buy physicians’ lunches.  The comments section of that article is surprisingly informative and thought-provoking.  An excerpt from the recent documentary The Vanishing Oath shows that many people think that doctors are in the profession ‘just for the money.’  Shadowfax argues that under some circumstances, fee-for-service is exactly the right way to pay physicians, whereas Dr. Wes thinks they should be paid by time, like lawyers (though I don’t know if he knows that there’s a movement among some lawyers towards flat fee payment structures).  He also presents pro and con arguments for what he terms “the corporate practice of medicine.”  Whatever choice you make, however, don’t make a mistake!  You will be crushed by a giant green Tyrannosaurus Rex.
  

• David Williams at the Health Business Blog reminds everyone that hospital visits should be BYOMD.

• Via Mark Perry comes this essay on wealth, wealth creation, the “rich,” and entrepreneurialism.  A similar theme is expressed more bluntly at The Volokh Conspiracy, discussing Ayn Rand. Coyote asks why government seems so hell-bent on putting more obstacles in front of entrepreneurs, in the context of tightened restrictions on “angel investments” in startups.

• 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.

• Here are three articles on a lighter note to close out this week’s edition:  Foreign Policy seems to overreach in calling this next century “the Canadian Century;” The Economist takes on job-title inflation; finally, Hit & Run looks at San Francisco’s recent ban on soft drinks in municipal vending machines, and compares Coke to the alternatives.