Friday, July 18, 2014

The population medicine approach does not respect the separateness of the individual,traditional or Rawlsian social justice nor evidence based medicine

 The population medicine approach does not respect  the separateness and sanctity of the individual and individual liberty. It is antithetical to not only traditional medical ethics but also to the ethics of classic liberalism. Further, it violates a major element in the concept of evidence based medicine, patient autonomy. It is not compatible with the social justice concepts as formulated by John Rawls and does not conform with the generally accepted meaning of social justice as redistribution from the less to the more needy.

The population medicine approach is basically utilitarianism which champions policies and actions that are supposed to bring about the greatest good for the greatest number. I say "supposed" because even the founder of utilitarianism recognized that logically and practically determining the aggregate utility or happiness did not make sense.Jermey Betham realized that adding John's happiness and Mary's happiness and subtracting Fred sadness was nonsense.

Quoting Bentham  "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 twenty apples to twenty pears, which after you had done that could not be forty of any one thing  but twenty of each just as there was before. ( ref. pg 136, A system of Liberty, by George H. Smith.) . Bentham admitted his "hedonic calculus" was based on a fiction  but he felt it was a necessary framework to get things done or legislation passed or policies accepted.

His approach echoes the thinking of the man who approached a psychiatrist and told him that he was very worried about his brother. Why are  you worried? Doctor, he thinks he is a chicken. Well, that is very serious you need to get him hospitalized.No, the man replied, we can't do that, we need the eggs.

 Bentham also needed the eggs.

 Everyone make decisions in everyday lives.It may not involve a formal or explicit cost-benefit analysis but it often involves a trade off. Utilitarianism goes beyond  making a trade-off within a person's life to the making of trade- offs between persons' lives and without their consent throwing the discreteness of individual under the bus. The population medicine approach does just that.

Consider the following quote from Dr. Harold Sox writing in the November 13,2013 issue of the Journal of the American Medical Association:Here he is  writing about allocation of funds occurring in the population medicine approach across patients and programs in which funds would be shifted to program in which the value was higher, as judged by QALY per dollar spent.

"It will take several generations to realize the full benefit of investments in disease prevention.In the short run,these investments draw resources away from tests and treatments from some sick people.In the long run, disease prevention and better low cost technology could reduce the outlay for treatment. In the interim, skillful clinical decision making can made the most of limited resources"
and
"Using the same metric of value and the same decision making principles for patients and for populations would be an important step toward a system that fairly allocates resources between the healthy many and the sick few."

The proponents of population medicine cavalierly admit there will be winners and losers. Dr. David Eddy in a series of articles In JAMA in 1995  said exactly that when he discussed the system that he proposed  as achieving better quality at lower cost. It was simply utilitarianism with cost effectiveness being a key metric in the allocations that would be made.Population Medicine is simply utilitarianism using quality adjusted life years (QALY) per dollar spent as the new metric of happiness or utility.

Sir J.A. Muir Gray writing in the Lancet (Vol 382,July 20,2013 ) in a commentary entitled "The Art of Medicine.The shift to personalized and population medicine" said in part:

'In the 21th century clinicians have a responsibility to the population they serves,to the patients they never see, as well as to the patients who have consulted or have been referred.,individual clinicians, while still focused on the needs of the individual in front of them when in the consultation, also make decisions about the allocation and  use  of resources to maximize value for all the people  the population they serve.This could be a decision that will reduce the amount of care that some would receive and increase the amount of resources for another group of patients,or perhaps put resources into education so that generalists can better manage the patient that specialists do not need to see."

Winners and losers but  more than that- Dr. Muir Grey would have the physicians also use their "charismatic and sapiential authority to promote health and prevent disease and encourages sustainable care , getting the best balance of benefit to harm, while minimizing the amount of carbon generated."

This is  a tall order- to balance care for your patient and everyone else and strive to save the environment.Medical schools will have to get even longer and harder to churn out docs with that skill set.Actually the rank and file docs will not have the allocation problem,the Platonic Guardians of Population Medicine will make the big decisions and the regular physicians will just adhere to guidelines.

The proponents of population medicine seem to think they have solved what Bentham thought impossible summing individual utilities by  using the QALY tool, quality adjusted life years which seem more scientific and objective that the "utils" of the early Benthamites.

 The ACP and ABIM Foundation are popularizing the new medical ethics. It appears that this new medical ethical system is an important prerequisite for population medicine  Here is how a former President of ACP, Dr. Harold Sox, ( ref. JAMA Nov.13.2013,vol310,no 8) explains it.

"Throughout history,codes of professional conduct have called on clinicians to make each patient's interests their highest priority.If resources becomes limited,clinicians will find themselves unable to adhere to that standard of practice for all patients.In 2002,a new code of conduct ,the Charter for Professionalism ,addressed this conflict by calling of physicians to consider the needs of all when treating the individual. While meeting the needs of individual patients,physicians are required to provided health care that is based on wise and cost-effective management of limited clinical resources.The provision of unnecessary  services not only exposes patient to avoidable harm and expense but also diminishes the  the resources available to others.
This remarkable passage indicates that the physician has an ethical imperative to balance the needs of the individual patient with the needs of society.With this foundational  principle of the population health approach, the Charter, in effect calls on clinicians to allocate resources. However, it does not provide specific advice. Recent programs such as the American Board of Internal Medicine  Foundation's Choosing Wisely campaign, are beginning to fill this knowledge gap, as do some practice guidelines." 

Dr. Sox speaks about "if resources become limited". By definition resources are limited. there has never been a limitless amount of medical care available.Apparently fiduciary duty to the  patient was acceptable as long as resources were not limited but by definition resources are limited.There has never been an unlimited amount of medical resources.

In this passage Dr. Sox ties together the Charter, the Choosing Wisely Campaign and the population medicine approach. Although Dr. Sox omitted mention, the Charter inserted a third ethical principle to the physician's ethical responsibility.It added to beneficence and non malfeasance, the furtherance of social justice which they stipulated was the fair and equitable allocation of medical resources which they later clarified  to mean that physicians should follow medical  guidelines based on cost effectiveness. But social justice as expounded by Rawls and as generally understood by many speople means redistribution to the advantage of the most disadvantaged and that is not what population medicine offers. Shifting of resources to one group from another based on comparative QALY calculations may or may not necessary benefit the most disadvantaged in society. The choosing wisely campaign began with a suggestion to which few physicians would object: eliminate tests and treatments that are harmful or wasteful. But it was not necessary to invent a new ethical principle for physicians to accomplish that goal. The ethical precepts of beneficence and non malfeasance covered that.One need not resort to claiming  that such act were required because physicians were the stewards of society's limited medical resource. It was sufficient to require that under the rubric acting a fiduciary agent of the patient.Further, the Choosing Wisely movement is morphing into something that some (see here) would want to be much more transformative.

Population Medicine approach is not compatible with the basic elements of evidence based medicine.Dr. David Sackett said:"Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care."

In the scenario described above by Dr. Sox in which funds might be diverted from someone's treatment to benefit some anonymous future person we hear no mention of consent of the patient.  Is it assumed that everyone will selflessly agree to sacrifice for the good of the collective.?Social and political schemes based on that principle worked out rather poorly in the 20th century.
The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuf

The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuHere is Dr. David Sacket's definition of Evidence Based Medicine (EBM) :"EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology". (Sackett D, 2002)What seems lacking in Dr. Sox commentary about population medicine is mention of the patient personal preferences and concerns and values. There is nothing said about how the patient might feel in the scenario Sox describes in which funds that could have been used to treat  some one's illness are diverted to some preventive program in which the result may take generations to be achieved. In a system in which its proponents admit there will be winners and looses we are not told to what extent if any will the values and wishes of the loser be considered .Drs Eddy and Muir Grey seem to assume that patients  will be just fine when funds are directed away from their or their children's or spouses  care to some other use judged to be more valuable or cost effective. Programs which depend on changing human nature have not worked out well.Look at the dismal history of collective planning in the 20th century.
The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serv - See more at: http://www.asha.org/members/ebp/#sthash.4MOV9yTv.dpuf
I submit that population medicine approach and the usual notion of social justice and in particular John Rawls's definition of social justice are not compatible. In fact much of Rawl's magum opus ,A Theory of Justice,was  written at least in part to refute utilitarianism  which is  a principle on which population medicine depends. Rawls said the utilitarianism did not respect the separateness of the individual and argues strongly against treating people as means some social end,In the case of population medicine , this would be optimizing the QALY or QALY per dollar spent.

To mix the concept of social justice and population medicine as done by spokesmen for the ACP and ABIMF is  a masterful muddle of mixing incompatible concepts and stirring it up with platitudes,gratuitous assertions and non sequiturs.


So, other than  that the population medicine approach contradicts traditional medical ethics,does not further social justice as it is commonly understood, flouts a key element of evidence based medicine,and requires individuals to sacrifice  themselves to some alleged greater good, it seems like a  pretty good idea.



Addendum: Minor editorial changes made 12/14/14.

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