If anyone has any lingering doubts that the promises of evidence-based medicine are quickly evaporating, the recent blog post by Larry Husten on the statin war should quickly dispel them. Husten gives an excellent account of the latest battle opposing the pro- and the anti- camps.
What happened?
The pro-statinists published a 30-page diatribe in The Lancet. Statins save lives, they assert. The evidence is incontrovertible. Yes, they can have side effects such as muscle pain, no one disputes that. But drawing attention to those side-effects—as the anti-statinists do—endangers patients who now find a reason to refuse to take the life-saving drugs. There’s evidence of that happening.
The anti-statinists voiced their position in the BMJ. Statins cause muscle pain and fatigue, they assert. The evidence is incontrovertible. Yes, they can save lives, no one disputes that. But trumpeting the benefits or down-playing the harm—as the statinists do—prevents patients from partaking in the glorious activity of “shared-decision making.” There’s evidence of that happening.
Unlike previous EBM skirmishes, where one side disputes the other side’s results (on the basis of, say, conflicts of interest or insufficient “data sharing”), in this present case both parties agree on the all the outcomes and all the evidence. This is astonishing and, in my opinion, a most wonderful development that patients and doctors everywhere should be cheering. It’s public proof that medical utilitarianism is a charade.
For decades, academic leaders and government policy wonks have constructed for us–piece by piece, admittedly–a system that would deliver “the most healthcare for the greatest number.” (How could we settle for less since we consider health care to be a human right?) The whole project, of course, rests on the assumption that healthcare values are objective, quantifiable, and subject to optimization in elaborate quantitative models. You can add them, multiply them, and divide them by 12. That’s the underlying assumption of “outcomes research,” evidence-based medicine, and related fields which are all basically utilitarian in their orientation, as Anjum and Mumford recently pointed out.
A few years ago, an international leader of the outcomes project described his field as “a scientific discipline [that would] bridge the capabilities of the medical profession and the best interests of patients and society”… “[with an] emphasis on the broad spectrum of patient outcomes in recognition that what seems best for patients and populations based on various sources of knowledge”…”to solve clinical and health policy problems.”
Unfortunately, the current statin conflict is seriously calling into question the ability of that science to achieve its lofty aim. How so? Though they may not yet recognize it, both parties in the conflict are giving us a clear demonstration of the inconvenient subjectivity of healthcare values.
As we saw earlier, neither side disputes the other’s claim regarding the particular rate at which lives are saved or muscles are in pain. But those in the pro statin camp value reducing the risk of a heart attack by a small percentage more than the price they are willing to pay: a larger risk of having side effects. And they hold that position not because there is a compelling mathematical reason to hold it. It’s not that 15 years of muscle pain equal one added life-year saved, or some explicit calculus of that nature. They hold that position as a preference. They hold it just because.
Likewise, those in the anti statin camp rank their preferences in the opposite order. To them, the small potential for life prolongation that comes with taking statins is not worth the greater likelihood of dragging one’s foot in pain for the rest of one’s life. And again, their position is not the result of explicitly quantifying and factoring the pluses and minuses. They hold that position as a preference, just because.
Granted, there is a material asymmetry between the two camps. The statinists have adopted a more authoritarian stance and feel that saving lives objectively trumps all other considerations. They even wish to suppress their opponents’ right to free speech by demanding a retraction from the BMJ. The anti-statinists, on the other hand, ostensibly only wish to express their alternative position so as to give patients the choice to take or reject the prescription.
Notwithstanding that difference, the point is that both statinists and anti-statinists are reputed academics in good standing who don’t disagree on the basis of numbers but on the basis of preferences. And personal preferences are what they are. No data in the world, pace the outcomes researcher, can alter that fact. De gustibus no disputantum est, as the wise maxim goes. If academics can’t agree on a scheme to resolve something as simple as one’s cholesterol level, what does the future hold for the scientific discipline that promises to “bridge the gap” between doctors on the one hand and “patients and society” on the other?
Of course, the collapse of utilitarianism will not happen overnight. The inventiveness of the wonks is not to be dismissed. They still have a lot of live ammunition at their disposal: “precision medicine,” “comparative effectiveness research,” the “patient-centered outcomes research institute” can all pretend to remove the chinks from the armor of the randomized controlled trial and of the meta-analysis.
But the healthcare engineers will not be able to hide behind obfuscating slogans for long. They may shout Less is more! or, alternatively, More is better!, invariably they will find someone who disagrees with them from within the ranks of managerial class. And that means a perpetual civil war among the wonks. That means game over for the grandiose plan of the utilitarians.
Grab the popcorn and enjoy the show.
“If academics can’t agree on a scheme to resolve something as simple as one’s cholesterol level, what does the future hold for the scientific discipline that promises to “bridge the gap” between doctors on the one hand and “patients and society” on the other?”
Love today’s essay! Am I wrong to find it reassuring at the individual level? I’m with the anti-statinists… “so as to give patients the choice to take or reject the prescription.” An informed patient can decide which route to go based on their personal—and quality of life—preferences while academics and practicing physicians on both sides duke it out. 😉
PS Rest assured I will share this with many.
Indeed! Thank you, Janice 🙂
Michel, thank you for this lovely piece, argued from a POV that seems distinct from the ‘obvious’ one that would appeal to Hayekian and Popperian ideas such as ‘scientism’, ‘historicism’ and ‘collectivism’. My first question would be: Are you working within/from one or more distinctly identifiable strands of thought? Basically, what I’m wondering is, can I read backward from your argument here, and learn something about a strand of liberal thought I have neglected?
My second question is: Where and how have you seen ‘precision medicine’ used as ‘ammunition’ by the ‘wonks’? My sense is that PM actually is an utterly devastating principle for disrupting (what I would call) the collectivist political theories of (what I would call) central planners of healthcare. That is, I suspect that PM (properly understood) can only ‘backfire’ if used as ‘ammunition’ by the … well, in the spirit of your ‘pace’ I won’t use the ‘e’-word … Opponents of the Open Society, let’s call them.
Thank you very much, David. I hope to stay faithful to the balanced realist school (Aristotle-Aquinas), and since empiricism is a dominant strand in modern medicine, I tend to be strongly anti-empiricist. In that sense, you’re right if you view–as I do–Popper and Hayek as still having inclinations toward empiricism (Popper more so than Hayek). One can have a libertarian interpretation of Aquinas (I do), but I don’t think that you would classify Thomists among the schools of liberal thought the way that term is generally employed, I don’t think :). As for PM, the term is vague enough that I thought I could use it to my advantage. I meant to refer to the possibility of seeing a regulatory framework controlling the use of genetic information (“for the common good”).
But seriously the value is accurate information (outcome data) to inform the physician and the patient. Different well informed patients will make different decisions which must be respected. Here is the key point: Paternalism is dying and the sooner the better. Accurate outcomes and impact data disempower the priests and empower the individual. This is progress.
I see your point but this really ignores the larger issue, that statins do not save lives, and that LDL cholesterol is not the cause of CVD. And that much of the harm done by statin drugs is caused by lowering LDL.
And yet this insight into the real medical issue is ignored! All the while elitests argue philosophy, the shareholders rub their hands in glee knowing it’s actually economics that’s the driver
Great article. It feels like the ‘utilitarians’ don’t really know how people are.
There are things worse than death, and life long pain is one of them.
Any amount of pain can rob one of energy and joy enough to make life a burden.
Doctors have no right to withhold information that would prevent individuals from making informed decisions about how much pain can be endured.
I agree completely with your argument which was perfectly nailed with the Latin phrase you quoted. (I had not heard that before and will definitely use that if and when I write about this subject again.)
I wish I could share your optimism about the game being over soon for the medical utilitarians . The folks, which I call the medical progressive elite,are very influential in national medical organizations ( e.g. ACP,ABIM) and the governmental units controlling much of health care and they play the utilitarian card very well to their advantage.
Bravo for a great commentary.
Thank you, James. I’m a part-time optimist. Perhaps the utilitarians will soon run out of other people’s money?
You have hit on the absolutely essential point here, which is that values are irreducibly personal. Sadly, many doctors feel free to heap abuse on patients who don’t share their values. However, I disagree that all sides agree on the factual issues. $ir Rory Collins is now claiming NNT numbers, for primary prevention, almost an order of magnitude smaller that you would get from Cochrane or TheNNT.com. Meanwhile, he and his cronies claim that muscle and tendon problems are very rare, that mental problems and the inability (especially for women) to benefit metabolically from exercise do not exist at all, etc. If you tell patients the lie that they have a 1 in 20 chance of benefitting, and the further lie that they only have a 1 or 2% chance of suffering a side effect, which then would be reversible … well, the patient never gets a chance to apply his values to actual data.
Rarely have i read such a fatuous waste of space- just another blowhard, sounding their own trumpet happy that there will be no rules, no guidance, no ways to improve- just the anarchy of I know best, or perhaps even more concerning the consumer always knows best, or more likely he just gets to practice in any way he likes-preferably with a good profit margin. Perhaps the improvements in medicine are all just ephemera -after all it’s all just relative really -all that measuring, methodology and medical knowledge- not really any different from homeopathy or crystal waving in a relative way. Seems to me you not far removed from anti-vaxers or flat earthers, after all that evidence malarkey is such a fag!
I’m sorry I didn’t include a trigger warning for the community of self-proclaimed skeptics!
Statins save 1 life out of a 100 in people who never had a cv event. Diet and exercise diet studies show better results.
Consider that in addition muscle cramps other side effects exist and since they are under reported we have no accurate way of knowing exact incidence: Short term memory loss, decrease of kidney and liver dysfunction etc.
Add to that a study of 136,000 heart attack patients (circ Jan 2009) where 72% had LDL levels at normal or low and a number of studies / reviews suggest that show that people over 60 with the lowest cholesterol levels have a shorter life expectancy.
a. British Medical Journal June 2016 (study suggested we need to rethink cholesterol role in heart disease)
b. Scientific World Journal May 2012
c. Circulation, issue 92, 1995
d. Lancet, issue 350, 1997
e. JAMA Issue 257, 1987 (“30 years of follow up from the Framingham study”)
Statins makers are just fighting for their livelihoods.
Amazing that the only “real” treatment of presumably too-high cholesterol is a pharmaceutical pill that inhibits the entire Mevalonate Pathway, inhibiting production of CoQ10 (your heart is a major user), hormones, dichols, etc., not just cholesterol production (if that is even necessary).
Can it be that other than medical considerations are at play here? Did doctors ever learn biochemistry? Do they really understand what they are prescribing? Have they thought any further than their prescription pad? Do their brains have a major need for cholesterol like everyone elses?