How private enhancement decisions led to a public health crisis

 

The proponents of using medical techniques not just for treating disease and dysfunction, but also for enhancing normal form or function, often appeal to privacy. Since most public and private insurance schemes do not pay for enhancement technologies, people who desire such “treatments” pay out of their own pockets; so, the argument goes, if they’re not hurting anybody, and they’re paying for it themselves, what’s the problem?

One of the more popular enhancement technologies worldwide is the cosmetic surgical procedure of breast augmentation. In the last few weeks a crisis of sorts has erupted around a particular brand of silicone breast implant, manufactured by the now-defunct French company Poly Implant Prothese (PIP) and exported all over Europe and South America. It turns out that the silicone used in PIP’s implants was not medical-grade, but industrial-grade, made to be used in mattresses; this may make the implants more prone to rupture. Rupture can lead to increases in inflammation and scar tissue formation.

About 300,000 of PIP breast implants are thought to have been used worldwide. This week, France and Venezuela took the step of offering to pay for the removal (but not the replacement) of all PIP implants. “We have to remove all these implants,” said Dr Laurent Lantieri, a French plastic surgeon “We’re facing a health crisis …” France will pay for ultrasounds every six months for those women who opt not to have the surgery.

Two things to note: first, removal of an implant is not like taking out a splinter. It is a major surgery, under general anesthesia, with all of the attendant risks — and expenses — of surgery. Second, other than those women who had implants inserted after breast cancer surgery, all of the women involved paid for their augmentation themselves. But now the state — that is, the citizens of France and Venezuela — will be paying for the corrective surgeries.

All techniques and technologies carry unintended and unforeseeable consequences. Even with the best planning and forecasting, all techniques will surprise us in some way. Medical techniques, because they work directly on the human body, have the potential and power to do very great unintended harm. The silicone breast implant crisis is an example of how choices made in private can have significant unforeseen consequences and costs for the public. The argument that using medicine for enhancement is merely an individual and private decision is simply not valid. How many more individuals will be hurt, and how much more will society pay, as enhancement techniques — and their unforeseen consequences — proliferate?

Losing control at Christmas

 

Throughout most of history, having children was not a matter of exerting control, but of accepting uncertainty. Whether and how the act of making love resulted in children was a mystery. In the pages of Scripture, having children — especially when one had been considered barren — was most often seen as a sign of God’s blessing: think of Eve, Sarah, Rachel and Leah, Hannah, Elizabeth …

Somewhere in the modern epoch the mindset changed. Children are still a blessing, but now they are also a liability, and we calculate how many hundreds of thousands of dollars it costs to raise a child. In the modern purview, since childbirth brings liability, it must be brought under control. The most portentous embodiment of this mindset change is the development of contraception. We now speak of “planned” and “unplanned” pregnancies — another way of saying “controlled” vs. “uncontrolled.”

But this is not enough control for moderns, for all contraception, other than abstinence, is imperfect. So when contraception fails, when we lose control, we establish the option of abortion, by which we re-assert control, by which we affirm the supreme modern value of control over life.

But even this degree of control is not enough. Why should we stop at merely preventing children, when we can control their conception? Thus we pursue reproductive technologies, by which the woman barren, like Rachel, or too-old-to-have-children, like Elizabeth, can produce a child. Yet this is still not enough; there is still too great an element of uncertainty, so we assert an ever-greater control over the process of conception by testing these children of reproductive technology before they are born or even en-wombed, in order to control who will live and who will not. Again, the mindset changes: children now are not only a blessing and a liability, but a product, manufactured to certain specifications and precise tolerances.

“Control” is not a bad thing. There are many in this world who would be much better off if they had a greater degree of control over their lives. But since we are a fallen race, the more we seize control of something, the more we ruin it in the process. We see this in our physical environment as we have increasingly asserted control over it; we will see it in our humanity if we continue in the path of controlling ourselves through enhancement and controlling our offspring through genetic manipulation.  One of the most vexing questions bioethics must answer is, How much control is right? And when have we gone too far?

Contrast the modern techno-birth with the most important birth in all of history, which was not a matter of control, but of surrender, surrendering control over birth. In the process, the “perfect” contraception — abstinence — fails! Yet from this act of surrendering comes the greatest gift the world has ever received. Is there a lesson here? Does our greatest good always lie not in grasping for greater and greater control, but in knowing when to relinquish control and surrender?

 

Of IOM, IT, EMRs, patient safety, and quality

 

If your doctor’s not looking you in the eye quite as much as he or she used to, it may be partially the fault of the Institute of Medicine (IOM).

In 1999, the IOM published a report entitled “To Err is Human: Building a Safer Health System,” which famously concluded that preventable medical errors cause up to 98,000 patient deaths annually. This was followed by the 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century.” These reports touted, among other things, the power of health information technology (IT), including Electronic Medical Records (EMRs), to reduce medical errors, increase patient safety, and increase the quality of medical care. Subsequently, the federal government has stepped in, providing financial incentives for physicians who can demonstrate “meaningful use” of an EMR, and will soon be imposing financial penalties on those physicians who don’t climb onto the EMR bandwagon. Thus, the IOM is directly or indirectly responsible if your doctor isn’t looking you in the eye because she’s gazing into a computer screen instead.

Upon what evidence did the IOM base its assertion that EMR’s would improve safety and quality? Well … you know … it’s just kinda obvious, isn’t it? I mean, after all, it’s technology, and it’s gotta be better than paper, and it just makes sense that using more technology is better, right?

In fact, there was no data to suggest that health IT would improve either the quality or the safety of medical care. In the intervening years, as health IT implementation has exploded, there continues to be a paucity of data to suggest that health IT improves either the quality or the safety of medical care. There is good data that it introduces new errors and quality problems into health care.

Last month the IOM released a new report, calling for the formation of an independent federal body to investigate patient deaths and other adverse events caused by … drumroll, please … health information technology.

Dr. Richard I. Cook, an associate professor of anesthesia and critical care at the University of Chicago, said, “It’s not surprising that such adverse events are being found related to health IT, and it’s not surprising that those promoting these systems have neither looked for them nor anticipated them. To make large-scale investments in these systems and only now be looking at the impact on patient safety borders on recklessness.” Dr. Scot M. Silverstein, a consultant in medical informatics at the Drexel University College of Information Science and Technology in Pennsylvania, said that it is “unethical” to expand health IT so dramatically without understanding the precise nature of the risks it poses to patients.

“Reckless” … “unethical” …

Meanwhile, my doctor’s still not looking me in the eye because he’s trying to find something in the computer. Sheesh! This is quality improvement?? Have we simply created a new “Quality chasm”?

 

(The quotes above are from this story which was published in the AMA news.)

Of Machines and Men (Part I)

 

As part of my job, I have the privilege of participating in the delivery of many babies.  I was at one such blessed event earlier this week.  There were several medical personnel and the father standing around the bed of the expectant mother. Due to the wonders of epidural anesthesia, she was quite comfortable, despite the fact that she was in the final stages of labor.

Suddenly I became aware of what all of us were doing — myself, my residents, the nurse, even the father: we were watching a machine. The mother was hooked up to a machine that monitored both the baby’s heart rate and her own contractions. The rest of us stood and stared at the machine. When the machine showed she was having a contraction, we would all turn towards her and encourage her to push, cheerleaders for her and the little life that she was bringing into the world.  But we kept one eye on the machine, and as soon as it indicated the contraction was over, we turned away from the mother and towards the machine again, waiting expectantly for it to tell us when the next contraction was coming.

With a sense of deja vu I realized that I had observed a similar phenomenon in the ICU: doctors, therapists, nurses, even family and visitors who had no idea what the little multi-colored squiggly lines on the monitor meant, nonetheless staring expectantly at the monitor on the wall instead of at the patient in the bed.  And in my training of resident physicians, I have watched videotaped patient encounters showing them sitting in the office with the patient, staring deeply into the computer screen instead of at the patient who has come to see them.  Similarly, in their inpatient work, the residents spend a few minutes on the hospital floor seeing their patients, and the remaining hours of the day (and night) staring into a computer screen, tending to the computerized chart — the “iPatient,” as Abraham Verghese called it here.

The practice of medicine has historically been founded on the physician-patient relationship;  on that foundation has been erected an edifice of techniques and technologies, tools for medical practitioners to use in serving their patients. However, it seems that in our time the tools are beginning to attack the foundation of medicine rather than just being used by it. For a variety of reasons, the tools and technologies increasingly become the center of the physician’s attention. Instead of medical practitioners defining how the tools are used, the tools begin to define what medicine is. We are becoming what Neil Postman called a Technoloply: our tools change and determine our practice’s purpose and meaning, our very way of knowing and thinking and relating to our patients.

 

Edmund Pellegrino once wrote, “Men have always sensed that the more they forged and the more machines they built, the more they were forced to know, to love, and to serve these devices.” (From Humanism and the Physician.)

 

Next week:  Some thoughts on what we can do about the ascendancy of the machine in medicine.

 

The limits of medicine and technology

 

In Too Much to Know, author Ann Blair notes that in our culture, which virtually deifies technology, we believe that we can find technological solutions to all problems, even those that are actually addressable only by attending to ourselves.*

Perhaps this confusion about the proper solution to a problem is part of the crisis in medicine and bioethics. The knee-jerk expectation of the public and the medical enterprise alike is that for every problem people bring before a doctor there can be found a solution, and that a technical solution will be the best. But what if that assumption is incorrect?

What if there are some patients for whom a technical solution is the worse option? Maybe there are some depressed patients for whom the best solution to their problem is not another pill, but the balm of human compassion and the encouragement to use the resources they have at hand to find comfort. Maybe there are some people with terminal diseases for whom the best solution is not every last possible intervention trying to sustain bodily function indefinitely, but rather help in strengthening faith and preparing for death.

Maybe instead of attempting to eliminate disabilities by trying to detect and eliminate fetuses that have them, we should be striving to be a people who can love and cherish those among us with worse disabilities than our own. Maybe instead of seeking absolute certainty (an illusion at best) by demanding that every technological test and scan be made available, we should be learning to live in the freedom of the inevitable uncertainty that comes with life on this planet.

Maybe there are types of human suffering that medicine was never meant to address. Maybe there are problems that we can only address by fixing not the problem, but our selves. And maybe part of the task of bioethics should be seeking the wisdom to discern between the two.

 

*This summary of Blair’s thought is from Alan Jacobs’s review in the May/June 2011 Books & Culture.

Physicians, Technicians, Clinicians, and Providers

A few weeks ago I had lunch with two doctors who are currently in a residency training program.  In a moment of candor, both of them remarked, “I feel like I’m being trained as a technician.”

This comment struck me as tremendously important (and not just because I am heavily involved in their training and their words highlight my failure as a teacher!).  Because if their perception is correct — if we are indeed instilling in future physicians the ethos of the technician — then we had best be prepared for the inevitable results.  “To a man with a hammer, everything looks like a nail;”  to a technician, every problem looks like a technical problem, one which needs to be solved by a technique or technology.  The dizzying upward spiral of health care costs is driven largely by the increasing use of increasingly expensive technologies;  training a technician workforce can only exacerbate the problem.  The technical bias towards the automatic, unreflective use of technology simply because it exists will lead to more of the inappropriate use of technological interventions that are the bread-and-butter of hospital ethics consultations.

But more importantly, not all problems in medicine are technical problems;  some are singularly resistant to simplistic, technical solutions.  For some conditions, the doctor is the best drug:  his or her human, caring, and compassionate presence, just being with the patient.  Yet to the technical mindset, this simply attending to the patient (from which we get the expression “Attending Physician”) is discounted in favor of doing things to patients;  and while both the being and the doing are necessary for the practice of good medicine, the standardization, mechanization, and industrialization of medicine in our day has heavily favored the latter at the expense of the former.  More often than our technical mindset acknowledges, it is better not to do something to the patient;  but this option is not in the purview of the technical mindset.  We always feel we must do something, and medical caring  often suffers as a result.  The central economy of medicine, the physician-patient relationship, is lost in the technical mindset.

The ongoing industrialization of medicine is reflected in and driven by the terms we use to describe doctors.  In the May 25th JAMA, the authors of an essay entitled “Dear Provider” wrote of the replacement of the title “clinician” with “provider.”  The authors believe that this semantic change could be subliminally altering professional self-concept and behavior, “shifting the clinical encounter from patient-centered to task-oriented.  Nowadays, patients are quickly ‘plugged in’ to templated workups;  progress notes have become computerized inventories of completed tasks;  and when we ask residents on teaching rounds ‘What do you think?’ we often hear ‘I think I want to get an MRI.’  It appears that the time and effort spent by providers packaging patients through the system is displacing most other clinical activities.”

Packaging patients through the system. Sounds like a technician’s handiwork to me.  How did we get to this?  Do we turn back or go on?

 

“Watson” vs. Humans

Watson supercomputer on Jeopardy.

Watson supercomputer on Jeopardy.Recently the quiz show “Jeopardy” pitted “Watson,” an IBM supercomputer, against the show’s previous top winners including Ken Jennings, the all time record holder for Jeopardy wins. With fascination, I watched “Watson” demolish the humans in a lopsided win. The event got me thinking. I tend to believe, contrary to futurists such as Ray Kurzweil and Nick Bostrom, that machine intelligence will never surpass human intelligence.

On the other hand, “Watson” “sounded” like a human and processed the information with a speed that surpassed the best human effort. Kurzweil, Bostrom and others believe that it is just a matter of time before technology will transform what it means to be human. The assumption is that human nature is malleable, not static. The hope is that technology can intervene to take humans to a higher level of existence and even immortality.

So my question is, what does this imply for human nature? Should Christians feel threatened by these developments?

Contemplating “The Scandal”

CBHD Scandal of Bioethics Conference Graphic

CBHD Scandal of Bioethics Conference Graphic

This coming July, the Center for Bioethics & Human Dignity will host its 18th annual conference. This year’s theme is “The Scandal of Bioethics: Reclaiming Christian Influence in Technology, Science & Medicine.” The conference theme poses a number of interesting questions that, I believe, would be worth considering in advance of the meeting.

First, do you believe Christian moral reflection has been marginalized in bioethical discourse and public policy decision-making, and if so, in what ways?

Second, what may we cite as the evidence of a contemporary bioethics bereft of Christian influence? How might the bioethical terrain differ from its present state if the Christian voice had enjoyed a more sustained presence in public policy discourse?

Third, to what may one attribute this marginalization of Christian moral reflection in bioethics? Is the problem external to the Christian community, or do we share in the blame? If the latter, in what way?

We’ll save the question of a way forward for another post, but perhaps you have other questions pertaining to the diagnosis of a diminished Christian influence in contemporary bioethics and its underlying cause(s).

Your comments?