The case against shared decision-making – 2

The meaning of patient

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This is the second part in a series on shared decision-making.  Click here for part 1.

A textbook case

I recently attended a cardiology conference where a speaker proudly presented a case of shared decision-making.  It involved a young female athlete who had survived a cardiac arrest and was diagnosed as having an anomaly in her heart conduction system, putting her at risk for arrhythmia during exercise.

She had received an implantable cardioverter-defibrillator and the decision in question had to do with whether she could resume sports activities or not.  The guidelines issued by the American Heart Association recommend that activities be strictly limited in intensity, but the evidence to support that recommendation is scant.

The cardiologist told the audience that he and the young woman met several times and had long conversations.  He got to know her very well.  He took the time to explain to her everything that medical science has revealed about the potential risks of a future cardiac arrest under the circumstances. Together, they imagined various scenarios of what might happen if one course of action or another was taken, and what impact the athlete might personally experience in terms of overall quality of life.

Finally, they jointly agreed on a decision.

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Alert & Oriented in the BMJ

A "head-to-head" feature with Dr. D. Francis.

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I was kindly asked by the BMJ to write a piece for a “Head-to-Head” feature on EBM.  Opposing me is the great Professor Darrel Francis, from Imperial College London and the National Heart and Lung Institute.   The resolution at stake was the following:  Does evidence-based medicine adversely affect clinical judgment?  I took the affirmative, of course, and Dr. Francis the negative.

Here is the piece (free access).

I’m very happy with it.  I think it’s my best effort against EBM so far, but you can judge for yourself.  Also, the BMJ is running a poll on this question.  As it currently stands, my position is trailing 40% against 60%.  However, given the pro-EBM indoctrination that has occurred over the last 30 years, I consider this to be a great victory!

The case against shared-decision making

Part 1 - The history of a nebulous idea

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In a matter of less than a decade, “shared decision-making” (SDM) has emerged as the uncontested principle that must inform doctor-patient relationships everywhere.  Consistently lauded by ethicists and medical academics alike, it has attracted the attention of the government which is now threatening to penalize doctors and patients who do not participate in SDM prior to providing certain treatments, even if the legal process of informed consent has been fulfilled—and even if the treatment is widely considered to be clinically justified.

For example, in a recent issue of JAMA, an editorial approvingly reports that the Center for Medicare and Medicaid Services will soon refuse to pay physicians and hospitals for the implantation of cardioverter-defibrillators unless the decision to implant these life-saving devices was “shared” with the patient.   Although the announcement is short on details regarding the formal process by which SDM must be documented to have occurred, the new policy certainly testifies to the unquestioned status SDM has rapidly acquired as a general principle of medical ethics.

Where does the idea of shared decision-making come from and how did it suddenly emerge to represent the highest of bedside virtues?  I will present historical development of that concept in this post and examine its highly problematic aspects in more detail in subsequent articles.

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How to rid medicine of its cronyism

An interview with G. Keith Smith

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Free-market medicine: Ethical, workable, unstoppable

We just did a fantastic interview with the legendary G. Keith Smith, MD, co-founder of the Surgery Center of Oklahoma.

Early in the interview, Dr. Smith speaks of the motivation that pushed him and his partner, Dr. Steven Lantier to divest themselves from the government-insurance-hospital system back in the late 1990s: They wanted to stop enabling what Smith identified as “financial serial killers,” so-called non-profit institutions that end up charging astronomical prices for healthcare yet have no qualms about bankrupting defenseless patients who are unable to pay those prices.

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Jade Eggs and Francis Bacon

Science, pseudoscience, and the goals of medicine

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How do we know that a treatment is bunk and doesn’t even need to be tested to be disproved?

A recent blog post by obesity expert Jason Fung ads fuel to the fire in the debate that opposes the standard-bearers of “science-based medicine” to those whom they view as practicing or promoting “pseudoscience.”

Fung attacked the perennial debunkers and his blog post prompted an immediate riposte by Dr. David Gorski.

Anish and I tried to sort through the controversy.

[Related post: Is medicine a scientific enterprise?]

Timestamps:

  • 00:00 Jason Fung’s case against the debunkers
  • 08:05 Anish’s criticism of Fung’s debunking
  • 10:50 How do we know jade eggs don’t work?
  • 13:20 Michel’s prior experience with being debunked by the debunkers
  • 21:40 The occult, the religious, and the naturalistic in medicine
  • 26:20 Medicine and science have 2 different aims; doctors ought to be clear about what health is
  • 31:25  Are the debukers baconian?  Do they know of the demarcation problem?  Is there a solution to the question of knowledge?

“No tears for you!” say the pharmascolds

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One of the most tiresome clichés in health care policy is the one that asserts that drug companies can mesmerize patients and doctors into using ineffective pharmaceuticals simply by way of an advertising campaign.

That claim was just made in the editorial pages of JAMA Internal Medicine and promptly spread via social media.  The editorial purports that Allergan has managed to make vast sums of money in sales of Restasis, a dry eye treatment, even though the medication is demonstrably ineffective.

Anish and I examine the claim and find it seriously wanting.  Here are the time stamps and the video (total watch time ~ 20 minutes):

  • A tweet catches Michel’s attention  0’30”
  • Anish summarizes the paper  1’30”
  • How do we know the drug “doesn’t work?” 4’20”
  • Anish presents his own market research…surprise, surprise, it’s Fake News! 9’05”
  • The “pharmascolds” are ideologues with no credibility 13’20”
  • Michel’s personal experience with dry eyes 16’04”

Futile treatments or futile lives?

A distinction that makes all the difference

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I was interviewed by Tom Woods on his great podcast.  We talked about the Alfie Evans case and discussed in depth the question of “best interests” of the child, and the appalling reasoning by which the UK medical authorities and the court decided that he was better off dead.  I think you’ll find the episode worth listening to.

In reading about the case I discovered that the UK judge presiding over the case was greatly offended by a comment made by Dr. Nikolaus Haas, the German physician who—along with the doctors from the Vatican’s Bambino Gesu Hospital—had offered to transport the baby out of the UK and provide the care that the parents requested, namely, placement of a tracheostomy and feeding tube so he could be cared for at home.

In his report to the court, Dr. Haas said the following, which the judge found “inflammatory and inappropriate:”

Because of our history in Germany, we’ve learned that there are some things you just don’t do with severely handicapped children. A society must be prepared to look after these severely handicapped children and not decide that life support has to be withdrawn against the will of the parents if there is uncertainty of the feelings of the child, as in this case.

That was an obvious reference to the dark, eugenics period of German history under the Nazi regime.

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“Real ACOs haven’t been tried yet!”

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What happens when you’re a healthcare policy wonk and the pilot study for your pet program has failed miserably?  You declare “Success!” in the editorial pages of the New England Journal of Medicine and demand that the program become nationwide and mandatory.

I kid you not.  This is exactly what happens.

Thankfully, Anish Koka is vigilant and explains the blatant obfuscations and manipulations that the central planners engage in to have their way.

In our latest video, we reveal the machinations, take the culprits to task, and discuss pertinent questions regarding health care organization:  Does “capitation” reduce costs?  Do employed physicians necessarily utilize fewer resources?  What happens when a HMO and a traditional fee-for-service health system operate side-by-side in a community?

Enjoy!

Does awareness reside in the brain?

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In his judgment about Alfie Evans rendered February 20, 2018, Justice Hayden of the UK’s Royal Courts of London writes:

Crucial to the decision I am being asked to make is the need to ascertain, as accurately as it can be, the present level of Alfie’s awareness.  Accordingly, I considered that an up-to-date MRI scan was a significant component in the broad sweep of evidence that was likely to inform this assessment.

Nowadays, it may seem obvious that an MRI should inform someone about another person’s level of consciousness because it is widely assumed that if consciousness is present, it must somehow be present “in the brain.”

I don’t have time now to discuss in detail why that view is not quite correct (you can sign up for my Philosophy of Nature and Man course if you have the urge to know!), but I am reminded of 2 amusing items.

The first is the following passage by E.A. Burtt (1892-1989), who may rightly be considered the first philosopher of science.  (In case you think I am sneaking in arguments from revealed faith, Burtt was a signer to the staunchly atheistic Humanist Manifesto II of 1973.)

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Cato’s Michael Cannon is terminally confused about Alfie Evans

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Michael Cannon, director of health care policy at the Cato Institute, has just published a piece where he criticizes conservatives for being “all wrong” about the Alfie Evans case which, according to him “had almost nothing to do with socialized medicine.”

As hostile as libertarians are to government, even we believe government can legitimately order the withdrawal of life support, and prohibit parents from moving a child to obtain further treatment, when that treatment would fruitlessly prolong a child’s suffering – i.e., when further treatment would be akin to torture.

But the court’s decision to prevent Alfie’s parents from obtaining the free care offered by the Vatican had nothing to do with limiting the child’s suffering.

As Cannon himself concedes, neither the court nor the doctors had any way of knowing if the child was suffering or not.  In fact, they were in agreement that the child was in a coma, without any awareness of the external environment (and certainly not subject to a treatment “akin to torture”).

What the court actually argued is that dying was in the child’s “best interests”—even absent pain and suffering.  That specific stipulation comes from recent guidelines by the Royal College of Paediatrics (RCP), which essentially argue that state-employed doctors can, by fiat, assert that a child’s quality of life is poor enough that he or she should die—and must die.

Cannon’s thoughts on Alfie’s case are still “tentative,” he tells us, but not tentative enough to take issue—as a libertarian—with a health care system where a government can forcibly prevent loving parents from providing life sustaining treatment for a sick baby at no cost to the taxpayer.  If the RCP’s guidelines are a perversion of medical ethics, Cannon’s position has got to be a perversion of libertarianism.

Meanwhile, if you would like a sane perspective on the insanity of the Alfie case, below is my latest video with Dr. Anish Koka, in which we discuss this at length.