Practicing medicine for the common good

Beware of the fallacies of Spaceship Earth ethics

By Forcastro - eigin skrá, Via Wikimedia Commons
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In a recent New England of Medicine article titled Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point:  Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each which his own physician.  The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving.  A decision to land midway must be made in flight, and it pits the interests of one against those of the other.

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Direct primary care for the poor

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A third-year family medicine resident inquires about the direct primary care model (DPC) and caring for the poor. (more…)

Against surgical excellence

How inept decision models are targeting surgical practice

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A Vox.com piece about decision-making caught my attention this morning.

The story was compelling.  A 12-year-old boy had intractable seizures from a leaking vascular malformation in the brain.  A first neurosurgeon would not operate and recommended radiation therapy instead.  The patient’s mother sought another opinion from a Mayo Clinic neurosurgeon who was adamant that an operation should be undertaken.  The second surgeon surgeon was undeniably right.  The patient is now a bright, fully-functional researcher at the University of California San Francisco.

So far, so good?  Not so, according to Vox.  That there should be a smart mom making a smart decision, and a smart doctor carrying out a successful surgery is apparently a problem.

Why?  Because the more cautious surgeon had a different opinion and, had the mom compliantly accepted his recommendation, the child could have been worse off.  Variability in judgment, as always, is the enemy.

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A free market repudiation of evidence-based medicine

A response to Andrew Foy

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In a recent article entitled “A Hayekian Defense of Evidence-Based Medicine” Andrew Foy makes a thoughtful attempt to rebut my article on “The Devolution of Evidence-Based Medicine.”  I am grateful for his interest in my work and for the the kind compliment that he extended in his article.  Having also become familiar with his fine writing, I return it with all sincerity.  I am also grateful to the THCB staff for allowing me to respond to Andrew’s article.

Andrew views EBM as a positive development away from the era of anecdotal, and often misleading medical practices:  “Arguing for a return to small data and physician judgment based on personal experience is, in my opinion, the worst thing we could be promoting.”  Andrew’s main concern is that my views may amount to “throwing the baby with the bath water.”

On those counts, I must plead guilty as charged.

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Mukherjee’s error and his critics’

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I can’t help but take a moment to comment on the heated response to Siddharta Mukherjee’s New Yorker piece.  Theral Timpson summarizes the kerfuffle very well, provides the appropriate links, and gives it its needed context.  The two posts by Jerry Coyne are worth reading, if only as a good education about what’s at stake.

The only interjection I will make is to say that neither side is getting it right or can get it right.  This is an example of the inevitable confusion that arises when one adopts the wrong metaphysical framework or, more precisely, when one pretends that metaphysics doesn’t matter because empirical science will tell us all we need to know. (more…)

Book review: How Doctors Think

By Kathryn Montgomery

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Kathryn Montgomery’s How Doctors Think: Clinical Judgment and the Practice of Medicine is an excellent book that was brought to my attention by Dr. James Gaulte in the comment section of my post on phronesis.  Indeed, much of Montgomery’s monograph deals with the Aristotelian concept of practical wisdom applied to clinical decision-making.

The author is Professor of Medical Humanities and Bioethics and Professor of Medicine at Northwestern University Feinberg School of Medicine.  Her book is too rich to cover deeply in a short review, but I’d like to highlight some of its major strengths as well as a few minor weaknesses.

In the first part of the book, Montgomery thoroughly demolishes the notion that medicine is applied science.

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The war on the NEJM

Under attack by the red brigades of transparency

The War on NEJM
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The war against the New England Journal of Medicine has gained visibility after Charles Ornstein traced its developments in the pages of the Boston Globe.  The story was amplified in a number of trade publications, and was even picked up by a NPR-affiliated show.

This has emboldened the attackers to open fire on Twitter with calls for “transparency,” “open science,” and a “unified research community.”   Their ideological alliance is with the BMJ.

Those who refuse to partake in the cause of transparency live in a world of “silos,” “conflicts of interest,” and “industry ties.”


The NEJM‘s lukewarm attitude towards the movement is “an oppression,” says Eric Topol, as quoted by Ornstein.  Did he intend to use a term with Marxist connotation? The loose coalition of scientists, healthcare journalists, and muckrakers ready to overthrow the established order might as well be known as the Data Liberation Front!

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Flexner versus Osler

Medical education suffers to this day

William Osler (1849 - 1919), left, and Abraham Flexner (1866-1959), right.  Public Domain, via Wikimedia.
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In the early part of my Mises Institute talk I expressed the following:

…under the dual influence of ideological empiricism, which was widespread among prominent scientists, and social progressivism, which was flourishing in many Western nations at that time, medical licensing laws incorporated and embedded the machine model into medical education, turning it into a quasi reality.

The convergence of interest between the social progressivists and the ideological empiricists, which led to the Flexner report and to the enactment of licensing laws, is further treated in an outstanding paper by Alfred Tauber, who was professor of medicine and philosophy at Boston University School of Medicine.

The paper, entitled “The two faces of medical education: Flexner and Osler revisited,” contrasts the radically different views these two men held about medicine.  It is ironic that the victorious viewpoint would be the one pushed by Flexner who, as Murray Rothbard put it, was “an unemployed former owner of a prep school in Kentucky…sporting neither a medical degree nor any other advanced degree.”

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From reacting machine to acting person – part 2

Greek mask (person), Louvre Museum.  Photo By Marie-Lan Nguyen - Own work, Public Domain
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This is part 2 of my paper presentation at AERC 2016 at the Mises Institute. Find part 1 here and the audio here.

Slide11I would therefore like to entertain an interpretation of health rooted in the view that human beings are persons acting purposely, persons who select means to achieve chosen ends, which is the framework of praxeology.

Under a praxeological framework, I would distinguish external means such as land, labor, and capital, which are generally the concern of economic theory, from internal means, such as the physical and mental conditions of the person that allow him or her to pursue chosen ends.

Health, then, may be defined as the state that is present when a person’s physical and mental conditions allow the pursuit of his or her chosen ends.  Disease, then, is the absence of health.

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From reacting machine to acting person – part 1

Claude Bernard and his pupils. Oil painting after Léon-August Lhermitte. Credit: Wellcome Library, London. Wellcome Images
via Wikipeida CC BY 4.0) 

Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
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This is the transcript of a paper I presented at the Austrian Economics Research Conference at the Mises Institute. I have included the slides below and you can hear the audio here.

The title of the paper is “From reacting machine to acting person: a praxeological interpretation of the patient, his health, and his medical care.”  For more info on praxeology, see my previous article here.

I have split the presentation into two parts. This is a very condensed talk, covering a lot of ground, but I will elaborate on various points I make in the paper in the ‘progress notes’ section of this website over the next few days and weeks.

Thank you for reading and for any feedback you might have.

The elephant in the room in healthcare is that there is no precise definition of health.  I believe that this ambiguity plays a major role in our perennial healthcare crises, and I am hopeful that Austrian insights can be helpful.

Here is the outline of my talk.

I will first identify the two dominant modes of thinking about health in modern Western societies.  I will show that those conceptual modes are counterproductive to fostering health, both economically and medically.  I will then propose a praxeological interpretation of health, and sketch the possible benefits and ramifications of that interpretation.

Slide3The dominant mode of thinking about health in Western societies owes its origins to René Descartes who, at the beginning of the scientific revolution, proposed the machine concept of the organism.  Descartes’ proposal was a radical departure from pre-existing notions which were rooted in the idea that organisms have essences and natures.  Instead, he proposed that every material body is an assemblage of tiny particles moving mechanically according to physical laws.  In the case of plants and animals, God directs the laws and the motions.  In the case of humans, the mechanical bodies are under the control of a separate human soul acting like a “ghost in the machine.”

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