Category Archives: medical ethics

Dr. Van Helsing Does Not Practice Primary Prevention

As recommendations for treatment of hyperlipidemia become broader and more generic, drifting toward the poly-pill conclusion, I can’t help but think of Dr. Van Helsing’s predicament in Dracula. In the story, though he has information which suggests the possibility of primary prevention, he practices secondary prevention. It is only after the symptoms appear – Lucy’s mysterious anemia and the rash of similar cases following her death – that the doctor suggests putting garlic around the windows. He has to wait. He’s in a story, so he knows the horrible truth all along, but he can’t reveal it without his patients sending him packing. Every doctor understands Van Helsing’s predicament. Few can see his patients’ logic however. It is one thing to indulge a crazy old man’s belief in vampires. It is quite another to indulge a crazy old man’s belief that a vampire has moved into the old mansion down the street and has begun to prey upon the household.
When doctors tell patients to treat public health problems, like cardiovascular disease prevention, on an individual basis, the patients take it as if they were being asked to put garlic around their windows because there have been vampire sightings in their neighborhood. They are slightly incredulous. And, the patients are right.
If we medical professionals are to treat asymptomatic individuals based on a 10 year risk calculated from epidemiologic data, for a disease which they have may or may not have started to develop, we must be honest with them. We have to admit that medication is the best that we can do, ask for their help, as a group, and then make it easy for them to help. Doctors don’t like to treat populations, though. Individualized care and patient centered care are the current watch words. But the greatest successes of medical science have been the opposite sort of effort. Nobody thinks that we should stop immunizing people for pertussis and move to an individualized prevention program with regular swabs for the pertussis bacteria and antibiotics for every runny nose. The approach is ostensibly patient centered, and it really is in a way, just like Dracula’s interest in Lucy and Mina is patient centered. Looking down from the established high ground, it’s easy to recognize the shift to an individualized strategy for preventing whooping cough as impractical and myopic. Medical professionals are clever enough to avoid bad moves from the general to the specific. However, decisions to move from a dysfunctional individualized program to a population based program can trip up anyone, even though the determining factors are the same.
The problem is Van Helsing’s problem. At the level of the vampire hunter’s interest, garlic around the windows is garlic around the windows. He’s like Dracula that way, for whom young ladies full of blood are young ladies full of blood. Dracula and Van Helsing are at risk of availability bias, cognitively and practically, as are all the physicians with lipid profiles, risk calculators and statistical correlations at their fingertips. There is a insidious, vampiric class of maneuver from population-based conclusions to individualized care. But the patients’ motivations lie outside of the action’s focus, and that focus is therefore myopic. It does matter to patients whether the doctor is asking them to deck the sills in order to cut down on the incidence of vampire attacks or because they should fear the vampire staring at them through the window. The latter request involves adopting an astringent manner of thought and behavior, the stuff of anxiety disorders. The former is an appeal to solidarity and public safety. We shouldn’t be surprised when the same people we’ve been instructing to fear the vampire outside their window come in demanding that we do something about the pale figure lurking behind their cough, in their prostate, or under their nipple. Having ceded the high ground, we’ve no credible response.

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The Word from the Land of Absolute Relativism

“Look at all this shit!”
He waved the stack of envelopes at me.
“Look at this one.”
He held up the letter on top. It was from another hospital and marked, ‘Important: Do Not Discard’.
“These are the ones you have to be careful to discard.”
He threw it in the wastebasket, and followed it with the rest of the unexamined mail. I was far enough into my training not to be shocked by this sort of thing. I’d weathered surgeon’s tirades and soaked up jaded, callous humor in the emergency room. Still, my experience with this psychiatrist had me believing for years afterwards that, in his specialty, like sought like.
“This kind of clutter is the enemy,” he continued, opening the top drawer in his desk.
He scooped out a handful of keys.
“Look at these! I don’t know what this is for,” he said, holding up a sturdy door key. Into the bin it went.
He tossed a few more, then dumped the remainder back in the drawer with an expression of disgust.
“We’ve wasted enough time,” he declared, “better show me the case.”
I handed him the chart, with my history on top. He lingered on the assessment at the bottom of the page. Residents sometimes began to sweat when attending physicians paused too long in their documentation review. I did not in this case, because the assessment was not mine in the first place; the patient brought her diagnosis with her from the last admission. He grunted and moved on to the ancillary notes, containing the comments from psychiatric nurses who had evaluated the patient.
“Jesus Christ! Did you read this?”
Now I began to sweat. I hadn’t read the nurse’s notes. He handed me the chart with a shake of his head. I’d gotten lucky; the question was rhetorical. Curiosity displaced my anxiety and I began to read with interest. Immediately, I realized what he was on about.
At the bottom of the page, several of the nurses (a cabal?) postulated that dark forces were at work in the patient’s life. The assessment dwelt upon the young lady’s practice of witchcraft, not as an expression of alienation in a personality dangerously adrift, but as an activity with sinister efficacy. I looked up at him as I finished reading.
“How can we hope to do anything for the patients when we’re up against this kind of stupidity from the staff? Borderline,” he stated, returning to my assessment, “Do you really believe that?”
I shrugged. She had the black nail-polish sign, which every trainee knew was pathognomonic for borderline personality disorder.
“There are some people that fit the bill, but mostly the term is an epithet applied to people who we don’t like because they are frustrating. It’s the DSM used as a cudgel, and it justifies our bringing these people into the institution when their community becomes too frustrated with their behaviors. They come in for a few days or a few weeks until they’ve cooled off, then they go back out with the same problems, to the same problems. So this kind of inpatient treatment is like firing into the tree line: it’s good for keeping the enemy’s head down, but it’s not good for hitting anything.”
His words were familiar in structure and reference. At home that evening, I poured through my memory and my boxes of books, and I eventually placed them. They recalled an image from Heart of Darkness.

Once, I remember, we came upon a man-of-war anchored off the coast. There wasn’t even a shed there, and she was shelling the bush. It appears the French had one of their wars going on thereabouts. Her ensign dropped limp like a rag; the muzzles of the long six-inch guns stuck out all over the low hull; the greasy, slimy swell swung her up lazily and let her down, swaying her thin masts. In the empty immensity of earth, sky and water, there she was, incomprehensible, firing into a continent. Pop, would go one of the six-inch guns; a small flame would dart and vanish, a little white smoke would disappear, a tiny projectile would give a feeble screech – and nothing happened. Nothing could happen. There was a touch of insanity in the proceeding, a sense of lugubrious drollery in the sight; and it was not dissipated by somebody on board assuring me earnestly there was a camp of natives – he called them enemies! – hidden out of sight somewhere.

The image stuck and grew stronger over the years until I ceased to see my preceptor as chief among madmen and came to see him as Marlow on the boat. He was the lone relativist in a wilderness of absolutists who considered borderline personality more than a label on a charge sheet (it is that at least, for the Diagnostic and Statistical Manual which codified the term is a tool intended to itemize mental illness for billing). For his fellow wardens of the institution, there existed a borderline personality fact about certain people, caused by borderline personality pathologies and amenable, potentially, to borderline personality treatments. He saw them firing into a continent. He did not, of course, live in the land of absolute relativism, where everything is an onion made of layer upon layer of motives and relations with no pertinent core. He believed in borderline personality as a country over yonder. It recognized certain commonalities, but those commonalities arose in the villages. They accrued; they did not come down from on high.
He cared about how seriously the nurses, psychologists and patients took diagnoses, not because relativism was true. He cared because absolutes did not obtain. Worse, absolutes destroyed. On occasion, bullets fired into the tree line did hit something, and that something was an enemy by definition. Over his career, he’d seen victory declared over schizophrenia and the state institutions emptied onto the street. He’d seen the profession take a pass on intractable diagnoses, like personality disorders. He’d heard from his predecessors about neurosurgical solutions considered quite successful in their time. It wasn’t that relativism was true, it was just that truth didn’t work that way. It wasn’t diagnosis-friendly, and the truth about psychology all the less so.

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Chaos Theory

The last several centuries have seen the rise of a perverse vision of morality. Going by various aliases this modern moral concept tells us that moral terms refer to something other than good and evil. Instead, the adherents of this viewpoint would ask us to believe that good and evil are mere descriptions, applicable to fashion choices as much as acts of benevolence or depravity. But the modern viewpoint is a lie. Descriptions have no power. They cannot motivate us to do anything. Of course, one suspects that the agenda driving our modern metamorphosis aims at a world where morality is not motivating. With moral focus dimmed, people can be motivated by those things which bring them pleasure and worldly profit. However, the agenda merely trades upon the normalizing effect of objective morality. We could not live as we do by following the path of moral relativism in real life.
Without objective moral terms, chaos would ensue. We do not have chaos, because moral terms refer to real things. Consider the alternative. If good and bad only operate within local frames of reference, we have a cascade of conflicting claims. Sometimes an act is good, sometimes bad. Sometimes an arrangement between individuals is evil, sometimes it is not. We cannot know which is which on the face of it. The authority of moral adjectives saves us from this fate. We need that authority to explain ourselves, and without it, we haven’t the motive power and clarity demanded by the moral challenges we face.
For example, walking among us is a small class of persons without remorse. They have no aversion to murder, and so require a reason outside themselves to condemn killing other people for any reason at all. Without objective moral terms, we have little to tell the psychopath. We can waffle about relationships and ties that bind, hoping to lash the psychopath to us with weak logic referring to dependencies. But what’s to stop him from replying in our own terms, like a serial-killing Popeye, “I am what I am and that’s right for me.”?
With objective moral terms at our disposal, we may respond with authority. “Murder is evil,” we may say, “and evil must be opposed.” A good moral concept is not just explanatory. A good moral concept tells us that we ought to do something, not just why we should think something is preferable. A good moral concept is solid, not riddled with re-words to the point of hollowness.
The moral troubles of the world require something with heft. Consider an even more difficult problem than individuals prone to violence: organized violence. Sadly, war is a fact of life. Our morality must confront it with an obligation powerful enough to justify such a monstrous activity . We can’t reasonably bomb the citizens of Dresden or Hiroshima and say to them or ourselves, “It is inconsistent with your identity as a human being that your group destroy other humans – the very source of that identity. Therefore you must die.”
We must provide a proper justification. We must say, “You have proven yourselves a proper medium for the perpetuation of evil. That is what we are bombing. Your deaths are regrettable, but that’s the best we can do and we are obligated to do our best when it comes to opposing evil.”
We cannot escape the reality of our moral terms, nor should we try. They are bound to catch us, because they do carry the obligations which we see at work in a just war. Nothing demonstrates our situation in that regard better than the way we deal with animals which kill humans.
If a bear kills a child, we execute the bear. We don’t kill the bear for any qualities relative to its bearishness, i.e. being a carnivore, needing to fatten up for hibernation, having an instinct to protect its young. We don’t care about the bear’s reasons; we care about the act. It has destroyed something invaluable. It has shown itself a creature with evil in its nature, and so must die. We are not angry at the bear. This is not revenge. This is justice.
Objective moral entities will finally allow no re-words at all. No relative merits, relations, revenge or reconsideration apply. Nor does scale. Absolutes do not mind scale. Evil is evil, and must be expurgated. What differentiates big evils from little ones is the ease with which they may be expurgated, not the strength of their demand on us.
The analysis at hand extends even to the smallest evils. Every year, 11,000 invaluable human lives are lost to infection with the bacterium Staphylococcus Aureus. We execute these tiny monsters with antibiotics. For the microbes which succumb, that’s the end of it, they have proven themselves minor evils and our obligation has been concomitant. But some do not succumb. Some of the bacteria are resistant to our antibiotics. In the case of the resistant bacteria, our duties are more complicated.
The bacteria in question, the resistant and the susceptible, live in people’s noses. The carriers of these bacteria are therefore complicit in the mediation of the evil which Staph. Aureus perpetrates. We may start by treating the carriers’ complicity as a minor evil and employ appropriate methods. We inform the carriers of their status and offer them the chance to eradicate the evil in their noses. History tells us that some of them will be unsuccessful. In those cases, a greater evil confronts us. The bacteria are persistent because they are resistant and so are better able to kill. As accomplices, we may treat the sub-group of carriers more leniently, though we are obligated to deal with the associated evil. These people have the choice of exile or suicide. These options neatly close the circle of obligation, but that’s not the important thing. What matters is that we have answered to our obligation. We have successfully solved the moral calculus and maximized human thriving. We can answer the carriers as we can answer the citizens of Dresden or Hiroshima. Your excision is regrettable, but that’s the best we can do, and we are obliged to do our best when it comes to opposing evil.

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There’s a Pill for That

While waiting for labs with me in the ER yesterday, a younger colleague made an offhand comment about quitting medicine. She felt frustrated because, instead of helping people get over their health problems and get on with their business, she spent her time treating public health problems in the clinic and emergency room. Even worse, she had begun to feel complicit in the distortion. I didn’t know whether to offer congratulations, condolences, or both. Most medical professionals never get that far. They continue to feel good about encouraging dialysis for blind, depressed diabetics with one remaining limb and prescribing cholesterol-lowering medication to nonagenarians. Thereby, only the superficial dissatisfactions of their jobs remain.

I don’t think that doctors should feel guilty about the public health problems confronting them in clinics. Nobody planned for our society to fail us. We spent so much of our history working so hard to make life easier and more certain that we just didn’t notice when we started working harder and harder to make life easier than we needed. The illusion of increasing certainty helped us zoom past the point of diminishing returns. Once enough surplus accumulated to ensure against starvation, twice the surplus seemed to offer twice the insurance against shortage, but the excess would only mold and spoil the lot. Our surplus is spoiling in us now, clogging our blood vessels and glycosylating our nerve fibers.

A solution to the problem lies beyond the scope of clinical medicine. The only solution may be time and economic dissolution. The furor over limiting soft-drink sizes in New York City does not bode well for self-conscious alternatives. But medical professionals can feel bad about their complicity in the whole scheme, because our business is to tell people that there’s a pill for all that.

We tell the public that we can “treat” and “manage” diabetes, coronary artery disease and heart failure. The proper terms would be “attenuate” and “temporize”. The proper terms would imply a lack of control however, and a sense of control is what we’re selling as much as medication or surgery. We keep the illusion of control on offer in the name of comfort. We want our patients to feel free from anxiety about their health. They should feel empowered, and they do, which is good since they will still be physically ill under treatment, just a bit less so than when they consulted us.

I guess there really is a pill for surplus-mold, at least on a psychological level, but it will cost those who take it a lot of money, and the motive to seek out the roots of their ailment. Besides, it will keep the doctors feeling good about something they shouldn’t be doing. It may appear to buy some time, but it won’t cure anything.

Buddy the Blastocyst Gets a Soul (or does he?)

Nobody likes abortion – not the people who go through the procedure, not the people who perform the procedure, not the people who make the rules – and for good reason. For the patient, it is emotionally and physically traumatic. For the physician, it is one of those sad duties on the ethical borders of the profession. For the society,  it is desensitizing and it ‘whites out’ a gray ethical situation. From proponents, abortion rights call for a sober advocacy, the kind of favor given a less bad thing. Only one thing makes the whole mess worthy of a fight, and that is the contention of abortion opponents that abortion is murder. To qualify as murder, Buddy the Blastocyst’s destruction must be the destruction of a human. To qualify as a human, Buddy the Blastocyst must have a soul. What makes the accusation of murder objectionable is the murder which justifies the accusation. That murder is the murder of the soul, or at least one concept of it.

Most religious people are dualists; they believe in a soul which is a substance separate from the body. In this model of the soul, the nature of the substance is a sort of nascent self- consciousness or quality of humanness – a realized version of what it’s like to be human. The soul then forms a nidus for the mind, as well as a motive force, and through its one-way, motivating influence on the mind, causes the body to act. Though the body’s actions may  indirectly represent the soul’s intent, the soul is only affected by its own decisions independent of the body and the parts of the mind that gather and manipulate information from the physical world. In this model, we are soul puppets. Though it is subtle and convoluted, this arrangement is necessary to have the soul be one substance with the deity. The deity then encounters no philosophical problems in being the direct creator and ultimate owner of the soul.

Obviously, skeptics and other monists do not subscribe to the soul puppet model. However, most still believe that there is something it is like to be human, and so believe in a version of the soul. But this version is a dependent soul. It derives from the gradual realization of the potential to be what a human is like, over an individual’s lifetime. The soul is thus an accretion on the body and mind, with the potential quality of humanness as its nidus. This is the idea of soul which the soul puppet people are bound to destroy. To properly understand this imperative, it helps to examine the implications of being a soul puppet for Buddy the Blastocyst.

Let’s say Buddy forms under the dualist model. He has a soul, created by the deity, which is a substance separate from his body and rational mind. His soul may indirectly affect his body and mind, and to remain a separate substance, may not be directly affected by the body and mind. As soon as Buddy comes to be, there is about a forty percent chance that he will  quickly cease to be. The uterus may not be ready for him or he may have a fatal genetic abnormality. For a variety of reasons, a large proportion of early pregnancies fail. On superficial examination, this fact seems to pose some problems for Buddy the soul puppet. Perhaps the deity is a cruel practical joker, who bestows Buddy with a soul only strip it away. Perhaps the deity knows Buddy will fail and so does not give Buddy a soul in the first place.

Buddy needn’t worry though. Just as the motives of his soul are not directly accessible to his mind and body, neither are the motives of the deity. In an ironic twist, the benevolence of divine caprice saves Buddy from predestination and arbitrary judgement. Just as the soul must affect itself and merely be represented in mind and body, so the greater material world must symbolize the deity’s motive, but in context of the deity’s real condition alone, which is separate and self-contained, completely encompassing and determining the material world. Otherwise, movements in the material world begin to operate on the same rules as in the divine, and so begin to have a direct meaning for the deity, bringing the deity under their influence (even if he/she must only choose to ignore them). Then he/she is no longer a separate substance, just a separate category.

So, Buddy is saved by never being able to know god’s mind through interpretation of material events. However, by the same ironic twist which allows Buddy the soul puppet to dodge potential problems with predestination and arbitrary judgement, the real consequence he suffers is condemnation to thorough-going Nihilism. He can’t know the motives of his soul in terms of material objects subject to his reason. He can rationalize the material representation of the deity’s will, though he can never know its significance. Forever pushing around symbols he can’t read in a game with rules not relevant to anything outside themselves, on all but the very deepest level, he is a zombie. But if he comes to see himself as a soul puppet, accepting the viewpoint of those who would call his destruction murder, his future can be a happy  condition of necessary ignorance.

The material world will no longer be a big problem once Buddy comes to that conclusion. It will be very convenient for him if he can rationalize its relationships, but consistency is not vital. Likewise, the moral sense that he may feel could be indigestion, but it may just as well be a one-way communique from his soul. He will be justified in believing his intuitions, though he can never really validate them. He then has a choice of two paths to follow. He can decide to do as the Shakers and others have and simply avoid confusing situations where an underlying psychological motive might masquerade as inspiration. Conversely, he can follow the majority of his fellow soul puppets, hold all his intuitions to be inspiration from the higher realm, and simply have faith that he is not deceived.

Still, it takes a tremendous amount of faith to walk about in pitch black dark. Like so many of us, Buddy may not cope well with uncertainty. He may seek solace in the scriptures which record  inspirational intuitions concordant with his own. History is cold comfort, though. He may wish to know something in his own time and space which validates his intuitions. Then, the only means available is comparison of his intuitions with those of others, and he may feel, since he is justified in believing his own intuitions true, that others’ intuitions must coincide with his own. He may demand a substantial soul for every blastocyst, and seek to silence any talk, or even implication, of an accreted soul.

The demand for consistency may seem inconsistent, but if it is driven by an intuition related to religious sentiment, the soul puppet may be justified in believing it is just as close to the truth as an action based on reason. Actually, if an intuitive conclusion cannot be related to a cause based in the material world, he may be more justified in believing such a conclusion is true. Distinguishing  discomfort from inspiration requires insight in the soul puppet’s world, and in that world insight is not more reliable than intuition. He might as well flip a coin.

This is the problem: in a material world where we are all weak from time to time, the soul puppet perspective ultimately requires universal participation. It is too uncomfortable otherwise, and in a system where the difference between discomfort and inspiration is not reliably discernible, relief becomes an imperative. So, the soul puppets are justified in crying ‘murder’, and more. They are justified in demanding that everyone else cry ‘murder’, and more. It isn’t abortion that’s a fighting matter, it’s the imperative behind the cries of  murder. Everyone may not agree on the nature of the soul, but no one wants to be a pawn in another person’s scheme to insulate himself from the implications of his own beliefs. Even a blastocyst deserves protection from that.

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Three Puzzles

“Goddamnit! Hold him down,” said the Chief.

His tone, which had been ironic and jovial as he bantered with the patient moments before, was now weary and annoyed.

 As the Chief rammed the blunt plastic rod beneath the skin of the man’s chest, under his collar-bone and into the incision in the hollow of his neck, the man bucked and screamed again. Nurses and medical students grasped his limbs to keep him on the table. The surgeons had taken every necessary measure to make the procedure safe and painless. They chose to place the catheter into the patient’s jugular vein under sedation to avoid the greater risks and side-effects of general anesthesia. They had even injected local anesthetic at the incision site and along the track the catheter would take from his mid-chest to the point where it entered the vein in his neck.

Not that local anesthesia could deaden such a large area. It mostly helped tamp down soreness after the procedure. But it needed do no more, because of the type of sedative used. Besides making a patient sleepy, the chemical was an amnestic; it reduced a human’s powers of memory to those of a goldfish.

As we wheeled him back to the recovery room, I leaned over the patient and asked, “Uh, how do you think that went?”

“Beautifully,” he said.

“No pain?”, I inquired.

“Not a bit,” he chirped, “and you know, I’m surprised how lucid I was. That was the best operation I’ve ever been through.”

I stopped dead in the hallway. At that moment, I understood the feeling my friend  had a week previously when he found out his parents aspired to zombiehood. They were, he had discovered, people who wanted ‘everything done’. He had tried to explain the predicament this created for him, and though I thought I had understood the situation based on our common experience as medical students, his complete perspective eluded me at the time. I thought his parents were just wrong because they knew no better.  Of course, we two medical students were horrified, since we knew what ‘everything’ really was and where it led: dull suffering, delirium, dead eyes in a live body, chest heaving to the click and hiss of a ventilator, then death, inescapable in spite of  ‘everything’. I hadn’t seen the other side of my friend’s dilemma: what is it like for the zombie? To become a zombie – a dying person bent on continuing to die – was to abandon a previous, more natural course but perhaps it was not a wrong act. Perhaps the transformation was like telling a goldfish in a bowl that it was doomed to swim in a twelve-inch circle until it died. The goldfish would suffer withering psychic agony for the three seconds it could recall the revelation, then it would return to contentment, unharmed. The vicarious regrets of the living  just might have a similar effect on a zombie, even the regrets of their former, living self.

And as the gurney bumped against the recovery room doors, I realized that I had faced this riddle once before and failed to resolve it. The riddle had come that time in the context of a story a co-worker told me. We worked together at a landscaping business. The guy was a mechanic, so he worked in the shop, while I worked in the field. Still, I got to know him well enough through shared lunch hours and down time with broken equipment to decide he was a decent guy. He was honest and, as a practicing Catholic, always trying to be good. And he was good, sometimes to a fault as he freely lent money to people who were unlikely to ever pay it back. Then he told me a story about when he was in the service.

He was stationed at a boring, isolated post. For miles around, there was nothing but irrigated fields, sage brush, and a few abandoned missile silos. Nothing moved on the landscape but jack rabbits and a few stray domestic animals. The jackrabbits were wary and hard to catch, but the strays would come to a kind word and an offer of food, so they were the ones that got tossed down the missile silos for fun. At first, the fading echos of the animals’ cries and the sparkling static on their fur were entertaining enough. Later, gasoline on that crackling fur added novelty to the routine.

He saw nothing wrong with ‘dog toss’. These were animals, after all, not conscious beings with a soul. As such, they could not truly suffer. What happened to them, as long as it was relatively quick and served a human need, didn’t matter. He thought this because he had been raised a moral realist and a deontologist. Good was a ghost in the ether, inhabiting certain acts and objects, imbuing them with its nature. All else was morally neutral. Other things rated only via human largess backed by tenuous relationships drawn between the hosts of good and those other things that his moral educators felt uncomfortable excluding from their calculus. Other things rated as bonus points. No one was going to hell for ‘dog toss’.

No one was going to hell for what happened under sedation with an amnestic agent either. The healthy body (even just a relatively healthy body) was a host for good, and that end didn’t just justify the means, it made them irrelevant. Proof  lay smiling on the gurney in recovery, ready for the next step in his embodiment of good, where his catheter would carry toxins to his blood to kill his tumors, his appetite, his hair follicles, his sense of smell, the lining of his mouth and colon, all to clear a space for good between his diagnosis of metastatic cancer and his death from it.

The doors swung shut and the surgical team turned away toward the suite of operating rooms where the next case waited. I did not follow. These three were related riddles, but they were not quite the same. Though I could now see it whole, the third puzzle still remained, and it was still the hardest. My friend’s parents were motivated by moral realism to have everything done. But whether their end came by age, chronic illness or catastrophe, the change from living to dying would come to them and sweep away any thought of ghosts and duty to ghosts just as surely as an amnestic sedative swept away all memory of pain and indifference to pain. Then it would be up to us – family, friends, doctors, hospitals – to tend to the ghost, or not. That was the hard part. Because we could deal with the creature before us, be it living or not, on its own terms, instead of trying to realize an apparition. And that meant denying metaphysical duty.

I stood for another moment while the surgical team gained some distance on me.

“I ought to walk out that door and just keep going,” I thought.

Instead, I put my head down and set off after the surgeons. I knew that I wasn’t doing the dutiful thing, but I was pretty sure that didn’t matter. Maybe all I could do was deal with what was in front of me, zombies and all. But even if I wasn’t up to the task of replacing them, I couldn’t keep serving  ghosts, theirs or mine.

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Autonomy

The quest for autonomy should be medicine’s ethical basis. A person afflicted with pain or debilitating illness can do little else but attend to the demands of their malady. Offer that person some relief, and they can better fulfill their potential. Whenever medical interventions achieve that goal, it is a clear win. All too often though, that’s the start of trouble, because winning is seductive, and it easily displaces less dramatic goals. Casinos could not survive otherwise. And when it comes to healthcare, we’re really in a sort of magic casino.

Players come in the door with a stake, but there are no bets and the only game is Blackjack. Rather than betting, we simply get to keep playing until the house wins and then we have to leave. Meanwhile, there’s the best cash bar ever, Cuban cigars – whatever floats your boat. And there’s more. Interventions are available for purchase. A player can buy the game down from  eight decks to one. He or she can spend a little more for the privilege of referring to a strategy chart during play. A little more buys a consultant to count cards for the player. Cards are even for sale. Between the dealer’s hits the house will give or take back a card for a price. All of these changes in the game are analogous to medical interventions in real life, from preventive care to emergency surgery.

The catch is, you can’t win. Sooner or later, the house hits 21 and you have to go. The trick is, remembering that you can’t win and playing to stick around and enjoy the bar and the Cuban cigars while you can. Ignoring your cards doesn’t make sense, but neither does hunching over the table with your card-counter whispering urgently in your ear.

Of course, the house could try to help the players out. It could require the purchase of a single deck game on entry. It could hire a concierge to tap players on the shoulder when they forget what they’re about and start to play to win.

Right now, the house of medicine is satisfied with being an honest shopkeeper. It is loath to get involved with purchase decisions because it mistakenly views those choices as, categorically, an expression of autonomy when they are not. They can lead to an increase in autonomy, but they can  lead to an ultimate loss of autonomy as well. Too many players are fixated on their hands in eight deck games, trying desperately to win, a card counter at their side and no cigar money left. Surely, we could do better.

Marketing a Pig in a Poke

Everyone knows better than to buy a pig in a poke, so selling one ought to be hard. It happens everyday in clinics and hospitals, though. Marketing is the key. The seller just has to convince the buyer that nobody really knows what’s in the bag, and that it might be really good. Fortunately, the task is easy for healthcare providers, because it’s just’ telling the truth. Much of the time, both parties can take a good guess at the bag’s contents. Sometimes neither is certain. In any case, a rational price is difficult to determine.

That’s why our current system uses baseline administrative pricing. There may be equally bad ways of pricing healthcare services, but there probably aren’t any better ways. At least this way, prices are based on an educated guess about what is in each bag.

Market pricing is an alternative method. It would give very good prices for squealing bags with pig-shaped lumps in them – things like Botox treatments and laser vision correction. Prices for bags with more amorphous lumps, containing things like cholesterol medicines, blood pressure medicines and cancer screening tests, not so much. The prices for those bags which, in livestock terms, could hold a pedigreed piglet or a skunk, would vary based on the buyers’ fears, hopes and disposable income. It’s a recipe for very good, cheap Botox treatments, and very good, cheap cardiac bypass surgeries and kidney transplants. It might not result in an efficient allocation of resources, but it would present an excellent marketing opportunity for those willing to prey on others’ hopes and fears.

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