Friday, August 31, 2012

ACP celebrates 10th anniversary of A Physician Charter -but all physicians may not agree

In the August 21,2012 issue of the Annals of Internal Medicine Drs.Christine K. Cassel,Virginia Hood and Werner Bauer have offered the readers a largely celebratory , somewhat self congratulatory and slightly cautious piece recognizing the 10th year anniversary of the Charter. They are referring to A Physician Charter.

In 2002, a group of internists from the American College of Physicians and the European Federation of Internal Medicine jointly authored a commentary that was designed to "supply a concise foundation that would shape how physicians viewed the practice of medicine."In this they not only emphasized how physicians would behave in regard to their patients but " toward society". It was this relationship to society which the authors said distinguished their work from previous professional codes. and there is no doubt about that.

The Charter spoke of a professionalism that consisted of three fundamental principles:patient welfare,patient autonomy and social justice. It was the term social justice that the charter authors used to designate this new emphasis on the relationship of physicians to society.

The term social justice has a long history but in general use in western democratic societies refers to a trend of thought that favors a greater degree of equality in regard to income and wealth and access to various institutional opportunities and equality of outcome in instances in which equality of opportunity does not achieve some notion of appropriate outcome. Redistribution to correct or mitigate various inequalities is considered part of its conceptual package.Social justice also emphasizes equality in general and human rights and human dignity.
The term social justice has a long history in religious thought, both Christian and Jewish and aspects of it play a prominent role in parties of the political left and is prominent in the expressed political philosophy of the the European social democracies.

Unfortunately for purposes of clarity of meaning the term social justice is often controverted and assumes variable meanings. Of course, from a tactical point of view those characteristics may have an advantage in a debate as opponents may find a elusive target.

The authors of the recent Annals article note that 130 organizations have endorsed the Charter and medical schools have embraced the professionalism that the charter defines.

However,as much progress as they claim has been made to make the idea of the medical profession as depicted in the Charter a reality, more needs to be done.There are gaps,according to the authors.

In regard to one such gap,I was surprised but pleased that the authors actually recognized that there remains some controversy.They admit that some object to the notion that physicians bear an obligation to serve the needs of society and to work to ensure a just distribution of health care resources. Of course that is where the controversy lies, there is no serious opposition of the ides of patient welfare and patient autonomy.

There was no scarcity of audacity in the charter when it a relatively small group of internists declared that to be ethical professionals one had to necessarily accept and work towards a political philosophy whose acceptance in United States was far from universal.

It is another chapter in the ancient tension between the individual and the collective. Physicians' ethics has traditionally been that of a fiduciary duty to the patient with a co-duty to some collective only being gratuitously added to discussion of medical ethics in the last twenty or so years,most famously in the Physicians Charter .

There are several-not necessarily mutually exclusive-lines of argument that disagree with the inclusion of a quest for social justice as a key element of medical ethics and which may well resonate with some physicians.

Here is a small sampling of some of those arguments:

1)Some may accept that social justice is a valid concept and one worth pursuing but see no reason to have social justice as one of the three fundamental precepts of medical ethics having heard no convincing argument for its inclusion. From my reading, a convincing argument for its inclusion was not found in the text of the Charter but seemed to be a gratuitous assertion.

2)Others believe that the concept of social justice itself is bogus,bereft of useful,meaningful intellectual content and operational details.Advocates of this position find support from the writings of Nobel laureate FA Hayek and economists Thomas Sowell and Anthony de Jasay and others.

Quoting Jasay. of the pathetic infirmities of social justice, namely that it has no rules by which a socially just state of affairs could ever be identified.

What rules do they advocate that would bring about an equitable distribution of health care resources.? Who decides what is equitable?

De Jasay speaks of justice as a property of an act and that an unjust state of affairs results from unjust acts. Who has committed the acts that lead to the unjust conditions that the social justice advocate yearn to rectify? (from The Collected Papers of Anthony de Jasay.Political Economy Concisely.)

Are the better-off obligated to help the worse-off even if their condition is no fault of theirs. What perversion of justice is it that places the " obligation of redressing an injustice on those who have not committed it."?

Social justice is when you blame someone for an inequality that they did not bring about and then make them pay to correct it.

By this line of argument social justice is not justice at all but a rhetorical tool to justify any and all plans for redistribution to rectify inequality in regard to any number of characteristics.

What is the argument for the claim that this egalitarian view with corrective redistribution must be a part of a physician's ethical package ? Would not one's choice in this regard be a matter for political philosophy and not professional ethics?

DeSay's arguments echo Hayek's ideas. To speak of notions of justice regarding the relative holding across an entire society is confused thinking in Hayek's view. Quoting Hayek:

Social justice does not belong to the category of error but to that of nonsense,like the term 'a moral stone'.

3) Others believe that the insertion of social justice into the medical ethical framework may or may not be unjustified intellectually and may or may not have meaningful operational content but more importantly it is harmful and has the potential to destroy medical ethics as it has been known and practiced for hundreds of years.

Dr Richard Fogoros on his blog The Covert Rationing Blog explains how the Charter and the New Ethics of the ACP differs from and conflicts with the old time medical ethics and warns of its harms.

The New Ethics takes classical medical ethics (which obligates doctors to always place the welfare of their individual patients first) and adds on to it a new ethical obligation, called Social Justice, which obligates doctors to work toward “the fair distribution of healthcare resources.” This new obligation (which is to society) will inherently conflict, at least some of the time, with the physician’s traditional obligation to the individual patient. So, under the New Ethics, the doctor’s loyalty is now officially divided. DrRich asserts that this divided loyalty (which is now declared to be entirely ethical) leaves the patient in a dangerous position, and breaks the profession of medicine

You will not find "fiduciary duty" discussed in the new ethics.New ethics advocates hope that if the word is not used that the obligation will go down the memory hole.Plaintiff attorneys may think otherwise.

Maybe the Mafia Rule (Cui Bono) does not always lead one to a useful insight but it often does. Who might benefit from this transformation of medical ethics ? The third party payers benefit because physician's ethics now include the precept to act for the good of the collective (third party payers and the ACOs will play the role of the collective) and if cost benefit analysis concludes that a given treatment is not cost effective then the ethical doc (by the Charter definition) will do what it right for the good of the collective. The medical elite might gain because they will be the ones who play a major role in writing the rules (guidelines) that will direct the ethical physician to act in the cost effective manner than will in the end benefit the group if not the individual patient and conserve society's resources. Are we looking at the old story of the baptist and bootleggers here?

Minor editorial changes made on 9/4/2012

Sunday, August 19, 2012

What does Massachusetts do when Romneycare costs too Much

The quick answer is blame the physicians and pass draconian,liberty crushing,contract abrogating, legislation to control medical care costs and physicians ' practices. See here for details from the WSJ regarding a bill passed by the legislature in Massachusetts awaiting the governor's signature.

Here is what the WSJ says regarding the physicians' control commission (my term for it):

An 11-member board known as the Health Policy Commission will use the data[ ED: data that the bill forces physicians to submit] to set and enforce rules to ensure that total Massachusetts health spending, public and private, grows no more than projected gross state product through 2017, and 0.5 percentage points lower thereafter. (And Paul Ryan's Medicare projections are unrealistic?)

No registered provider is allowed to make "any material change to its operations or governance structure," the bill says, without the commission's approval. The commission can also rewrite the terms of provider contracts with insurers and payment levels and methods if they are "deemed to be excessive."

Apparently for physicians to be "allowed " to practice they must submit the required economic data to the commission .

So a physician is not allowed to change the operation structure of his practice (whatever that means) without the approval of this board and so much for the sanctity of contract as this group can "rewrite" the physicians' contracts. This outrage would have a good fit in the descriptions of various frightening government actions found in Atlas Shrugged.

If this does not encourage docs reaching close to retirement age to retire early what would? At least physicians there can move to another state and seek refuge at least for a while until Obamacare costs reaches some levels when something like that is imposed nation wide.

We already have in the wings, awaiting its operational birth according to the ACA timetable,an organization that either already has or is ready to assume the power to control not only Medicare and Medicaid expenditure but all medical expenditures according to some nonsensical projections of what medical costs "should be" versus some fairy dust projection of GDP growth. Well why not, after all central economic planning worked out really well in the 20th century. This panel of Platonic Guardians is known as IPAB. See here for more on that.

Does anyone think we will hear howls of outrageous protests from such organizations as AMA and ACP? Another question- what does his legislative act do to retainer practices?

Addendum and update 8/21/2012 The governor has now signed the bill- so it is law.The tireless Dr. Douglas Peredia has read through the 349 page document and has extracted the key provisions (39 pages).See here.

Wednesday, August 15, 2012

Basis of Quality Adjusted life years is a fiction Ask Jeremy Bentham

There was a time a few years ago when there was sincere honest thoughtful criticism of he concept of quality adjusted life years (QALY) , not so much now.In 1990 (JAMA 199:263(21):2917-2921), John LaPuma and Edward Lawlor published thoughtful critique of QALY. They said that the QALY concept was :

founded on six ethical assumptions: quality of life can be accurately measured and used, utilitarianism is acceptable, equity and efficiency are compatible, projections of community preferences can substitute for individual preferences, the old have less "capacity to benefit" than the young, and physicians will not use quality-adjusted life-years as clinical maxims.

In their article they offer valid critiques of each of those assumptions.

But the dogs bark and the caravan moves on. Pick up almost any issue of JAMA and the Annals of Internal Medicine and you will find articles on the cost effectiveness of some or other medical procedure or treatment.

Now it seems that the notion of QALY is well ensconced in the practice of " determining" the cost effectiveness of medical procedures and treatments. Why is the word determining placed in scare quotes? Because my argument is that the idea of determining QALY is, in the words of the founder of utilitarianism, a fiction.

Jeremy Bentham did not discuss QALYs since the term was not invented in his day but he did consider the idea of adding up individuals happiness or utility as it was essential to his philosophy.

Bentham's famous principle is "the greatest happiness of the greatest number is the foundation of morals and legislation". To him happiness was the balance of pleasure over pain and this would be summed up somehow for everyone affected by the policy proposal and was known as the principle of utility and is the essence of utilitarianism.

Those who favor a utilitarian approach to public policy issue will not be pleased to learn than Bentham himself admitted that summing happiness or utilities or some measure of quality of life did not make sense. Bentham wrote:

"Tis vain to talk of adding quantities which after the addition will continue distinct as they were before,one man's happiness will never be another man's happiness:a gain to one man is no gain to another;you might as well pretend to add 20 apples to 20 pears,which after you had done that could not be 40 of any one thing but 20 of each as there were before. This addibility of the happiness of different subjects , however, when considered rigorously it may appear fictitious, is a postulatum without the allowance of which all political reasoning is at a stand.."

So Bentham realized that adding up everyone's happiness did not make sense (when considered rigorously) but we need to do it to make policy.

The economist, Anthony de Jasay ,said that scientifically speaking aggregating the utilities of different persons, e.g. to subtract from the gains of some the losses of others,is just as nonsensical as taking four apples out of seven oranges.So nonsense that is "useful" for some analysis is still nonsense.

Cost effectiveness analysis as applied to medical procedures does not exactly sum happiness over many individuals but sums instead quality adjusted life years. The QALY ( or the simpler concept of life years) is foundational in the current efforts to determine cost effectiveness.

John Rawls' A Theory of Justice proposes a redistribution scheme different from utilitarianism about which he said "[it]does not take seriously the distinction between persons".Thomas Nagel,a critic of utilitarianism said of it that it treats the needs and satisfactions of multiple individual beings as if they were the features of some hypothetical mass person.

Nonsense or not it is a handy tool for the elites who would make their value judgments determinative of what the rest of us are allowed to have in terms of medical care.

note: minor editorial changes made 8/16/2012 in the final paragraph to clarify meaning.

Wednesday, August 08, 2012

USPSTF-Thanks goodness they have"no emotional,ideological or financial conflicts of interests"

Dr. Otis W. Brawley,of the American Cancer Society, characterized the USPSTF as ideally suited to provide an objective,unbiased assessment of the state of the science (medical science in this context as it applies to screening for disease) because:

"The Task Force Members have no emotional,ideological or financial confidants of interests."

This quote can be found in the Annals of Internal Medicine,Prostate Cancer Screening: what we know,don't know and believe" (Annals Int Med. 22May 2012.)

Somehow the appointment process utilized by the AHRQ (Agency for Healthcare Research and Quality) which,as best I can tell, appoints the members to the Task Force, is able to cull out potential appointees who have ideological and emotional conflicts of interest as well as the more easily determined financial conflicts.

The techniques employed by AHRQ should be made public as appointing individuals without any biases would be incredibly important in regard to the judiciary (particularly the Supreme Court) .Such a determination would be invaluable for voters in selecting a candidate.AHRQ has an ethical obligation to make this marvelous selection process public.Their vetting process seems to have discovered a new group (sub-species?) of humans who are except from the cognitive flaws that psychologists such as Daniel Kahneman and Amos Tversky, have described. Other authors such Drs Jerome Koopman and Pamela Hartzband have commented on the subjective elements in what passes for objective analysis of medical data;the public is fortunate to have decisions made for them by a panel who can be objective all the way down.

Quoting Koopman and Hartzband:

For patients and experts alike, there is a subjective core to every medical decision. The truth is,despite many advances, much of medicine still exists in a gray zone where there is not one right answer"

Panels designated as expert have at their disposal sophisticated statistical methods and standard epidemiological concepts, but at the end of the process some one or some group has to make a value judgment. Some one has to say the risks are or are not worth the benefit.

The financial conflicts , or course, are the easiest to discern. Ideological biases is a little more difficult to exclude. As far as "emotional biases" I have no clue as to what a litmus test of that would be,but apparently Dr. Brawley does as does the AHRQ.

The majority of Task Force members come from medical academia. If it were the case that medical academicians as a group are of a certain mind set or world view it would be specially important to weed out those whose priors might include a certain default view about screening for what ever reason.

It is commonly held the academics in general are more likely for example to vote democratic than republican and are more likely to be characterized as progressive rather than conservative or libertarian and tend to vote than way. Fortunately there is nothing in the progressive world view ( which posits that elites should make the really important decisions rather than the individual) that would lessen their ability to make an unbiased assessment.

Many of the task force members have MPH degrees or more advanced degrees in Public Health. Could it be the case than special training in public health might lead one to adopt (or seek such a degree because one has already adopted ) a world view in which the inevitable tension between the good of individual versus the good of the collective is more than a little slanted towards the later. Perhaps, but presumably AHRQ vetting procedure has been able to select candidates who have no prediction for either position.

Rather than declare than the task force is composed of creatures marvelously bereft of any and all biases and thus describing creatures not previously known to exist on earth I suggest the following description is more realistic:

Highly trained,well educated conscientious, fallible people trying hard to make the best decision they can dealing with difficult information supplied with less than complete information and using mathematical tools that offer approximate answers rather than categorical eternal truths.

Does a person's priors (past experiences,education,world view) inform the way they read the data in regard to a certain issue.? Common sense , general experience and a great deal of generally accepted psychological research all suggest the answer is yes.

Paragraphs of over done, self serving sarcasm may give some personal satisfaction but my first reaction to Dr. Brawley's statement was the phrase made famous by John McEnroe referring to a shot by his opponent that everyone in the stadium but the umpire saw that the ball was out is really all the claim deserves. "You've got to be kidding me."

Friday, August 03, 2012

There is no "i" in team,Dr Wes on the Penn State Mentality in Physicians

Quote for the day:

Dare we ask what we are creating as we move to make doctors shift-workers, business minded. algorithm-driven, group-think, productivity-incentivized cogs in our new heavily-funded health care wheel. Paying doctors for performance standards based on computer-driven check-boxes, guideline adherence and proscribed health care is of more importance than the individual. Health care, then, devolves to nothing more than a nine-to-five series of clicks.

The above is from the typically insightful blog of Dr. Wes. In this commentary Dr. Wes makes a thought provoking analogy to the Penn. State tragic horror show. Go here for the full story.