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.
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.