Tag Archives: healthcare

The Harder Problem

I have a purple shirt, or maybe it is royal blue. I was never in doubt about the color until my wife called it blue one day. Up until that point, I never even contemplated calling the shirt blue, or that there might be a difference between my perception of the shirt’s color and her’s.

Maybe there still is not a difference. Maybe our perceptions are the same and the words we use differ unnecessarily. If I look hard, though, I can see how she would call the shirt blue.

Her and my perceptions are almost certainly not the same, nor are anyone’s. The alternative – that people disagree about colors, and so much more, because our language is massively mistaken – seems too incredible. Shouldn’t we have ferreted out even the most minor issues by now? After all, we do so well at finding agreeable words for so many things, even in the realm of aesthetics.

Plus, there is a good explanation for the source of disagreement between me and my wife on my shirt’s color. If one tracks back how each of us learned to classify blue and purple experiences, there are substantial differences. And, those differences do not only effect our use of words; those differences also condition our purple and blue perceptions .

Yet there is another problem lurking. Even if I could magically take a snapshot of my brain at the moment in which I saw the shirt as purple, and show it to my wife, not as a map or photo, but as exactly the same state of affairs imposed upon her neurons, she could still differentiate it upon reflection. The brain state in question would always be her experience of my experience, rather than simply her experience. My experience of the shirt’s color cannot be captured, as mine, by means of physical reproduction.

One might ask, who cares? The upshot of our limitations is tolerable. Big truths may be a little counterfeit by implication, but we are accustomed to working with flawed notions already, and do fine by it. For example, Newtonian mechanics serves us beautifully, even if it is not ‘really true’.

Yet, we do not tolerate our flawed notions. An optimist would say that we are not satisfied with lesser things, and are constantly trying to improve our understanding. Our behavior suggests otherwise, however. We want big truths in principle, and the certainty, the reality, that comes along with them. In physics, we don’t just want quantum mechanics and relativity, we want a theory of everything. In ethics, we want good and evil, and duties to serve.

So, the hard problem does matter, because it is motivating. And, it moves us to a harder problem. We want things to be true which are not merely false, but which are incapable of being true or false. The idea of a concept not being truth-apt is slippery, so an illustration is in order.

Consider the case of Baby K. Baby K was born over two decades ago without a brain. Not only was she(?) born, she pulled off a feat which few anencephalics manage; she lived more than briefly. Or, she maintained a metabolism more than briefly, because her status as a living thing, much less a living human infant, was in question. She would never see a purple shirt, or a blue shirt, or have any experience at all. And since our personal experience is what we value above anything (what choice do we have, after all?) some people felt that a creature without experience and incapable of it was not truly alive, much less human.

Baby K’s mother disagreed. She felt that K was born of a human, exhibited some behaviors, had a heartbeat, and therefore fit into the human peg-hole, albeit imperfectly. K’s remarkable persistence owes to her mother’s insistence on aggressive medical interventions for K, based on K’s status as a human baby. For K’s mother, the rules of classification were categorical. There are Forms in the world, according to this school of thought, and the Forms suck their creatures in, even the most flawed copies.

When Baby K had trouble breathing, her mother took her to the ER and demanded that Baby K be saved, put on a ventilator, and nursed back to health in the ICU. But was health one of K’s capabilities? She needed saving, but for what, and from what? We could not ask K about any of this, ever, even in principle. As her physiology counted down to its end, what was there to distinguish this tick from the following tock, and so provide a basis for valuing more of the physiological process?

When K came in to the ER, the professionals on duty did not want to treat her. Since she was incapable of experience, she had nothing to value (there wasn’t even anyone there to value anything). Efforts to ‘help’ K were therefore empty. There was nothing to help with and no one to accept the helpful gesture.

Remarkably, some argued that further medical interventions merely prolonged K’s suffering. Perhaps they meant to say that further interventions caused the staff to suffer. More properly, futile actions degraded the integrity of the medical professions. We become what we practice, and if the medical professionals practiced service to the beating heart, then they rightfully feared that they would become servants to the beating heart.

The hospital also expressed concerns about the resources that K consumed. This argument was a utilitarian argument and failed in the usual fashion. If K did not occupy the ICU bed, the bed would not move to an under-served area, nor would the unexpended cost of K’s breathing tubes and procedures be converted into mosquito nets for children in malaria-afflicted territories. Values are not generally translatable, any more than their costs are portable.

But the missing cipher in the professionals’ calculation was K’s value to her mother. Someone did experience K’s physiology after all. To waive K’s value on that account was just as degrading as crass service to the beating heart. If the medical professions seek to serve health, and health is function, then the milieu is everything. It was a mistake to consider K’s value on the basis of K’s intrinsic capacity for experience, just as much as it was a mistake to think that the ventilator was saving K herself from or for anything. However mistaken she was about Forms and their efficacy, K’s mother valued K’s beating heart in a consistent way. Harm would come to the mother from K’s heart stopping. It would be the same sort of harm – loss of experience and the possibility of experience – to which the professionals referred in their assessment of K’s lack of value.

All along, the players in the Baby K saga evaluated her with standards that did not apply – that were not truth-apt. It was never the case that Baby K was human or not, alive or not. Her case nicely demonstrates the nature of the harder problem. Our standards – good, evil, human, matter, energy, mine, yours, blue, purple – are not stand-alone things. They are made of their circumstances (our circumstances). Without a doubt, the standards serve us well, since our circumstances are necessarily shared. If the standards refer to the specifics, and the specifics are near enough alike, it’s just good fudging to defer to the standards. It is easy to forget that the standards defer to their instances. And we are motivated to forget, because we value our experience and we value our standards, and we are prone to equate the two.

 

 

 

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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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Cult of the Range-Fed Turtles

When my best childhood friend grew up, he decided to become an archaeologist. During his graduate training, he was in charge of  a dig in the Mississippi river valley which unearthed an odd structure. In the midst of the native people’s dwellings, was found a circular enclosure made of closely spaced wooden posts and containing a large pile of turtle shells. The undergraduates were eager to speculate about the purpose of the structure, but my friend cautioned them against it.

“We can’t be sure of its use,” he said”, and we can’t just guess based on what we might use an enclosure like that for today. We can’t just assume they were running a turtle ranch here. Why would they do that with a river full of turtles just a quarter-mile away? We have to put it in context of the surrounding village and the environment of the time, look for other examples and see if there are any modern structural analogs. Then we can make a guess, but it will still just be a guess.”

The next day the professor in charge of the dig came around on a rare site visit to see how things were proceeding. The students were eager to show him the mysterious ring of posts with its pile of shells.

Upon seeing their find, the professor remarked without hesitation, “Huh, must have been a turtle pen,” and promptly resumed his walking tour of the dig.

I don’t know if archaeology has an excuse for this kind of thinking, but medicine does:

Life is short. The art is long. Experience is difficult.

– Hippocrates

We can be forgiven for resorting to teleological assumptions now and again in medicine. With limited time and incomplete information, we must sometimes act on hypotheses which attribute function to structure and purpose to processes. Lucky for us, there’s plenty of slop in the system, so even if we’re wrong at the start, we usually get a second chance. We are trying to get away from teleology, though. “Evidence based medicine” and “scientific medicine” are the names that we have given that effort.

We are trying to get away from teleology because we have been burned by it. We thought that the body made pus to fight off bacterial infections, so for years, when we saw people with respiratory illness cough up phlegm with pus in it, we gave them antibacterial medications. We were wrong, not just about the purpose of pus, but in attributing a purpose to pus. Again, it was an understandable mistake, given the long history of debate regarding the merits of pus. Was it a good sign, or a bad one? Should we encourage or discourage its formation? It turns out we shouldn’t have been focusing on the pus at all, but on    the outcome of our purposeful intervention in the underlying process that produces the pus.

Purposeful results and final causes apply prospectively to human endeavors alone, and even there it’s often difficult to tell whether, when our actions are associated with the desired result, the outcome is due to our actions or simply due to fortuitous circumstances. Applied retrospectively or to processes and structures beyond our control, teleology is a sure mistake.

When we assign an endpoint to a process, we presume causation and correlation must be proven. Humans are notoriously bad at that. In systems which we can’t duplicate or control, we can always tell a causal story (I’m looking at you evolutionary psychology, intelligent design, cosmological fine tuning). But those stories are just interesting rationalizations, sharing the merits of a fairy tale in that they reveal more about us than the subject matter. Our fairy tales are harmless when they are about the universe, the origin of life, turtle ranches or anything else beyond our control. When we tell teleological stories about processes we do seek to influence (and can) we court tragedy.

The practice of bleeding was based on one such tale: the story of homeostasis. We still tell it today, but we tell it as metaphor instead of fact. The story is based on the simple observation that, when a person becomes ill, they go through a series of changes in their physical state which ultimately ends in either the restoration of their previous state, or death. Having observed other systems, the Greeks thought that the process of illness looked like a disequilibrium. Having observed associated changes in fluids which emanated from the body, they attributed the disequilibrium to an imbalance in those fluids. We can hardly blame them for the limits of their observations. We can’t fault their hypothesis. However, we can fault their method.

They didn’t just postulate an imbalance in the humors as a cause of illness, they presumed a balance of the humors as a state the body sought. The difference in these two points of view is subtle, but crucial. If  the balance of fluids is seen as descriptive  then restoring health by balancing the fluids remains a working hypothesis. It admits that other factors may determine the observed equilibrium. It leaves open the possibility that the observed flux of humors is a secondary phenomenon. Most important, it leaves physiologic equilibrium as a simple description, instead of presuming that it is a purpose with causal powers.

Given a description and a working hypothesis, physicians would look at their efforts to balance a patient’s humors with a critical eye. As a teleological assumption, with equilibrium as a “final cause” under Aristotle’s system, the idea creates an entirely different viewpoint. With  humoral balance rooted in the body’s design, variances in expected observations must be due to inadequate methods or incomplete knowledge of the humors. For this version of the “balancing the humors” hypothesis, failure is not an option.

Now, the ancient Greeks may have weathered this kind of assumption better than their heirs. They loved to fight with each other. In the face of inconsistent outcomes from humor-balancing interventions, they were likely to call Aristotle and Hippocrates idiots or just ignore the under-girding theory of causes altogether in favor of their own pet theory. Definitive statements naturally took a healthy beating in the Greeks’ intellectual environment. The Romans, and the Europeans who came after them, were much more pious.

As a result, no one questioned the teleological assumption, out of reverence for its sources, and the vital fluids persisted in medical thought owing largely to the idea of homeostasis by design. No matter how apparent the flaws in our understanding of the blood, bile and phlegm, they were somehow attached to the homeostatic goal of the body. As long as physicians saw that equilibrium as the body’s goal, they could reconcile any discrepant observations with the over-arching story and persist in practices such as bleeding. It fell to investigators outside of the medical profession to discover the secondary nature of the humors. Only then did the practices aimed at balancing the fluids truly begin to fade.

But long after bleeding and the balance of fluids fell by the wayside, the tale of homeostatic purpose continued to plague medical science. Physicians continued to view physiology as directed toward an end. For example  the heart was seen not to pump blood, but to be a pump. Therefore, medical students were instructed to never administer medications called beta-blockers to patients with heart failure.

Beta-blockers stick to proteins in the membranes of  heart cells called beta receptors, which normally bind adrenaline. Via the beta receptor proteins, adrenaline stimulates the heart to pump faster and with more force. In heart failure, the heart can’t contract forcefully or fast enough to keep up with the volume of blood returning to it from the veins. If the heart is a purpose-built pump, beta blockers should be anathema in the setting of heart failure. But in reality, when given to stabilized heart failure patients, beta blockers reduce long-term mortality by about one-third.

We don’t yet know exactly how these medicines achieve such a feat. We do know why they are not inevitably detrimental in heart failure. It is because the heart pumps, but it is not a purpose-built pump. The heart is instead a group of cells which inhabits a specialized niche in a system of many cells all with complimentary and competing characteristics, existing in a state of equilibrium which, in deference to tradition, we call homeostasis.

Our physiology doesn’t try to maintain homeostasis any more than erosion tries to form a natural arch. The arch forms (rather than crumbling like the sides of a stream-bed) because it is geometrically stable given the geology. The arch persists because it is geometrically stable, and so we frequently see natural arches where the climate and geology allow. Nobody marvels at this, speculating about a conspiracy between sandstone and weather patterns. Then again, few people have an emotional stake in natural arches. The same is true of our physiology, minus the low stakes. There is no overall homeostasis sensor or hormone in the body. There is no homeostasis conspiracy.

So, we have abandoned the notion of purpose in physiology, and that simple maneuver has allowed us to discover things like the survival benefit which beta blockers produce in heart failure. This move is the principle behind the randomized, controlled clinical trial. All along, it wasn’t ignorance holding us back, but the project of rationalizing our knowledge to traditionally understood, teleological models.

Of course, the questions driving evidence based medicine don’t start from nowhere. Scientific medicine asks questions based on the results of previous investigations and hypotheses derived from basic science discoveries regarding the components of physiology and their relationships. Some of these hypotheses are even most easily stated in terms of purpose. But those statements are now understood as metaphor, rather than bare fact.

Beyond the fecundity of this change in method, the move away from teleology finally brings some redemption for poor Hippocrates. Rather than using it as an excuse, we can understand his aphorism, “Life is short. The art is long. Experience is difficult “, properly again – as an admonition about method. Be skeptical. Remember that your viewpoint is limited. Watch out for overarching narratives. Good advice, and not just for medicine, but for all those turtle-ranch theorists out there (I’m looking at you intelligent design, cosmological fine tuning, evolutionary psychology…).

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Carnival of Adverse Selection

A Canadian friend once told me that he did not understand the American political system and asked if I could explain it to him. I told him that it was basically an exercise in pest management. On the one hand you have your smarmy rats (Democratic politicians) and on the other you have your vicious rats (Republican politicians). The first kind you don’t even want near you, the second kind you just want to stomp. Either way you’ve got an intractable rat problem, so mostly you just try to ignore them as best you can and get on with your life.

Sometimes though, they crawl across the kitchen counter in broad daylight and then you have to pay attention to them. That happened to me during the last Presidential debate. I was doing my best to ignore it, but we have a radio in the garage with a power switch stuck in the ‘on’ position and the debate was playing in the background. I had it successfully tuned out until they started talking about health care and Romney, who’s turning out to be a particularly nasty little ankle-biter, came with the crazy talk.

Here’s what he wants to do about health insurance:

  • Block grant Medicaid and other payments to states, limit federal standards and requirements on both private insurance and Medicaid coverage. The state can structure a cost-share program however it wants?  It can still shift costs to the Emergency Rooms of Medicare-participating hospitals and to the Medicaid programs of richer states (a kind of internal ‘self deportation’ which already happens to a limited extent)? I can’t imagine what the states might do? These changes are supposed to lead to innovation, and they will – just more the sort of innovation that financial system deregulation allowed.
  • Unshackle Health Savings Accounts by eliminating the minimum deduction requirement and allowing people to use the account funds to pay premiums. HSA’s are a nice product for a very limited income range. If you make too much money or too little to make the tax savings worthwhile, a HSA makes no sense. The proposed changes won’t change that. So, why make the changes? Hang on a minute, I’ll get to that.
  • Allow consumers to purchase insurance across state lines. Recall this is the now minimally regulated insurance product. Watch the insurance companies gobble each other up as they try to recruit all those newly available good risks. Watch high risk people get filtered out of the broader  insurance pool as the generous benefit plans become increasingly burdened with these individuals, and the prices for those plans go up and up, in turn prompting lower risk people to leave for cheaper, less generous benefit plans. Will Romney & Co. adequately fund a reinsurance plan to keep this from happening? Not to worry, people with chronic problems can still go to the ER, right? People can preemptively accomplish this adverse selection themselves via purchasing pools, right?
  • Medicare will become a premium support program. The premium support and benefit requirements will be fixed at the current levels in Medicare. If costs go up, the market will determine how people make up the difference. And in time, like gravity takes care of shoddy construction projects (who really needs architects or building codes), the market will take care of things by channeling the high risk people into the more generous plans (Medicare), driving those plans’ costs out of sight and eventually, driving those plans and high risk  people out of the market. I can almost hear the invisible hand slapping – see adverse selection and cost shifting above. (It’s actually worse than that – Medicare has a normative effect that goes beyond its simple economic effects but that is a story too long and tangential for the moment.)

So, why make the changes if they entail all these predictable distortions? Free market fundamentalism is the answer. Markets aren’t a highly effective tool for these guys, they are a moral imperative. So in their view, markets must be good for every application. Just set up a market and have faith; it will solve any problem. Regulation and critical analysis aren’t caution, they’re apostacy. I’d usually ignore this crap, like I ignore people praying for rain, but this is more like praying that your kid gets better from leukemia in lieu of consulting an oncologist. I feel like I’ve at least got to say something.

So, for all who wondered what could be worse than Obamacare – it’s this happy horse shit. These two rats are scampering across the counter in broad daylight with this mess, and they need stomping, (metaphorically of course).

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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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