Medicine • Philosophy
When California Governor Edmund Gerald “Jerry” Brown, Jr. signed into law ABx2 15, legalizing assisted suicide in the state, he issued the following statement explaining the reasoning behind his decision:
In his 1993, John Paul II had this to say about the kind of examination of conscience through which Governor Brown would become “certain” about the comfort that the law would provide him and others:Continue reading “At the tribunal of Jerry Brown’s conscience”
In a recent Harvard Business Review article, authors Erin Sullivan and Andy Ellner take a stand against the “outcomes theory of value,” advanced by such economists as Michael Porter and Robert Kaplan who believe that in order to “properly manage value, both outcomes and cost must be measured at the patient level.”
In contrast, Sullivan and Ellner point out that medical care is first of all a matter of relationships:
With over 50% of primary care providers believing that efforts to measure quality-related outcomes actually make quality worse, it seems there may be something missing from the equation. Relationships may be the key…Kurt Stange, an expert in family medicine and health systems, calls relationships “the antidote to an increasingly fragmented and depersonalized health care system.”
In their article, Sullivan and Ellner describe three success stories of practice models where an emphasis on relationships led to better care.
But in describing these successes, do the authors undermine their own argument? For in order to identify the quality of the care provided, they point to improvements in patient satisfaction surveys in one case, decreased rates of readmission in another, and fewer ER visits and hospitalizations in the third. In other words…outcomes!Continue reading “Neither expert nor businessman: the physician as friend.”
I told you before that I would do my best to avoid bringing up phronesis, but a superb essay by Lisa Rosenbaum, national correspondent at the New England Journal of Medicine, is forcing my hand.
In “The Paternalism Preference — Choosing Unshared Decision Making,” Rosenbaum calls into question the gradual shifting of the burden of decision-making onto patients in the name of informed consent and autonomy.
The essay begins by examining the issue from the patient’s perspective, but Rosenbaum’s reflection then turns to the role of the physician. She remarks:
But science cannot answer a question at the core of our professional identities: As information-empowered patients assume greater responsibility for choices, do we assume less?
The answer to that question has to do with our understanding of what constitutes good medical decision-making. Clearly, the prevailing notion assumes that good medical decisions come after a rational approximation of an objective biological reality, a “predictive analysis” that forms the core of “evidence-based medicine.”Continue reading “Phronesis”
[I’m on summer break but I thought you might enjoy this piece, published a year ago in the August 2014 issue of the Nob Hill Gazette. The version below is slightly edited compared to the original.]
In their recent book titled, Dr. Feelgood: The Shocking Story of the Doctor Who May Have Changed History by Treating and Drugging JFK, Marilyn, Elvis, and Other Prominent Figures, Richard Lertzman and William Birnes chronicle the startling career of Max Jacobson, a physician who specialized for decades in treating celebrities with his personally concocted injections of vitamins, human gland extracts, and high doses of amphetamines.
Operating from a filthy office in Manhattan, Jacobson showed no regard for basic medical hygiene and never obtained a basic medical history from his patients. Yet, over the years, he dispensed untold quantities of his “cocktails” to political and show business superstars suffering from fatigue, pain, or lack of stamina. For some of his patients, such as Cecil B. DeMille, the German-born doctor was a paragon of modern medicine. But others saw their careers and personal lives ruined as they became addicted to the treatments, and a few might have actually died as a result of it. The authors of the book relate instances where, under the influence of Jacobson’s amphetamines, President Kennedy’s behavior became wildly erratic. They even speculate that a motive for his assassination might have ensued.
Max Jacobson’s story might seem like a sordidly entertaining tale from a bygone era. Nevertheless, given our current love affair with medications (one in five adult Americans takes a psychiatric drug, and 70 percent of the U.S. population takes some form of chronic prescription medication), it behooves us to reflect on the professional and ethical failings of Jacobson’s practice to help keep our way of “better living through pharmaceuticals” within healthy boundaries.Continue reading “Feel-good medicine: yesterday and today”
[The following article is published with the kind authorization of its author, Herb Fred, MD, MACP. It first appeared in the Fall 2004 issue of the Texas Medical Board Bulletin.]
For the past two decades, medicine has been a profession in retreat, plagued by bureaucracy, by loss of autonomy, by diminished prestige, and by deep personal dissatisfaction.¹ These ills would be bad enough by themselves. But another malady confronts us—the sagging of our professionalism.Continue reading “On the sagging of medical professionalism”
Over at the Incidental Economist, Austin Frakt has published a thoughtful commentary on Lisa Rosenbaum’s NEJM series on the obsession over conflict of interest. Frakt is supportive of Rosenbaum’s position but also touches on a dimension to the story which I did not address in my admittedly polemical piece yesterday.
Frakt’s most important statement is actually not in the post itself but in a Tweet linking to it.
I view COI disclosure as (meta) data. Like all data it doesn’t self-interpret. This is the source of all COI-debate: http://t.co/qIyds8T6Bu
— Austin Frakt (@afrakt) May 22, 2015
Frakt is absolutely right and his statement points to a very fundamental assumption that underlies not only the COI concerns, but the legal practice of medicine in general. Namely, the assumption is that in science and medicine, we should “let the data speak for itself.”Continue reading “COI and empirical fundamentalism”
Irvine Page’s 1987 medical textbook Hypertension Mechanisms begins with the following acknowledgment:
My special thanks are due to the Ciba-Geigy Company, who not only has contributed generously to the financing of this book, but who–over the years and more than any corporation–has recognized and encouraged the development of research in hypertension
The famed Cleveland Clinic physician-scientist, who died 4 years after the book was published, would not live long enough to have to apologize publicly for this colossal evidence of conflict of interest (COI). It would take a few more years and a few scandals to set into motion the current phobia against industry influence. In fact, Page would undoubtedly be stupefied by the rituals we now go through to show that our research and opinions are unblemished by the taint of for-profit corporations.Continue reading “COI in medicine: the pharisees exposed!”
[This essay was published in the May 2015 issue of San Francisco Medicine. The entire issue is devoted to obesity and you may find it on-line here. ]
A war on obesity has been declared. Public health authorities have identified excess body mass as an epidemic threat. With a great sense of urgency, they are mobilizing resources to address this preeminent health concern. To bolster the effort, the American Medical Association has recently decreed obesity as a disease. Local, state, and national political powers are now engaged in its eradication and have enlisted the assistance of a number of celebrities.
But does the war on obesity have clear objectives and a sound strategy? Will the campaign be conducted as a targeted strike with a well-defined exit plan, or will it turn into an open-ended conflict with limited prospects for victory? Will the offensive conform to “just war” principles, or will it be mired in moral confusion? Whatever the answers, I have reasons to object to this war.Continue reading “Against the war on obesity”
[As part of the debate on physician-assisted suicide, the San Francisco Medical Society kindly invited me to write an article taking the “contra” position. Below is the text of the article. You can find the print version along with the article taking the “pro” position here.]
When a terminally ill but mentally competent patient wishes to die, should a physician be allowed to bring about such wish? The California legislature is considering that question, and physicians will soon be asked to weigh in on it. Until recently, so-called “physician-assisted dying” (PAD) garnered little support among doctors. Currently, however, enthusiasm in its favor is growing. What are the reasons given to justify this emerging practice? Do they truly warrant legal sanction? And do they justify an about-face from the medical profession’s long-held stance on this matter?Continue reading “A deadly choice for the medical profession”
There’s been a bit of a buzz following the release of the latest edition of the ACP’s Ethics Manual. For the first time, it seems, the manual includes a section on “stewardship of resources” with directives summarized in Box 4.
The Left hailed the new change as “truly remarkable” and an important first step to “break the logjam” of health care deficits, while the Right was quick to denounce the set of instructions as an “ethical game-changer,” a surreptitious undermining of the doctor-patient relationship, or an overt step toward health care rationing.Continue reading “Box 4 of the ACP’s ethics manual”
