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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Monday, July 16, 2007

    Virtuous Medicine: Jacob Sullum on the tyranny of public health:

    ...Nevertheless, doctors generally assume that the high priority that they place on health should be shared by others. They find it hard to accept that some people may opt for a brief, intense existence full of unhealthy practices. Such individuals are pejoratively labeled ‘noncompliant’ and pressures are applied on them to reorder their priorities.”

    This is what H.L. Mencken had in mind when he remarked that “hygiene is the corruption of medicine by morality. It is impossible to find a hygienist who does not debase his theory of the healthful with a theory of the virtuous. The whole hygienic art, indeed, resolves itself into an ethical exhortation. This brings it, at the end, into diametrical conflict with medicine proper. The true aim of medicine is not to make men virtuous; it is to safeguard and rescue them from the consequences of their vices. The physician does not preach repentance; he offers absolution.” Whether or not you agree with Mencken’s view of the physician’s proper role, the danger of transforming a doctor’s orders into the government’s orders should be clear.

    This is what worries me the most about the current trend toward "pay for performance," in which doctors are rewarded if their patients meet certain health goals - diabetics keeping their blood sugar within acceptable ranges, people with coronary artery disease keeping their cholesterol levels below certain levels, for example. (Having patients weigh in at healthy levels isn't one of the quality measurements at the moment, but it could be eventually.) By tying physician payment to patient behavior, we run the risk of turning even the most libertarian physician into a tyrant.

    posted by Sydney on 7/16/2007 08:17:00 AM 6 comments


    Worse, you risk turning even the least compliant patient into a pariah.

    By Anonymous Anonymous, at 9:17 AM  

    Politicians have a bottomless thirst for ever greater tax-inflows, which their authority to spend enhances their political power (and their sense of personal power).

    There could come a day when an individual's medical records (yielded to the IRS) might determine how much in extra personal taxes he pays -- the degree to which he is overweight, for example.

    Farfetched? No one surveying the political/cultural landscape today should have strong doubts.

    In every form of government present in the world today and in the past doctors have been used, willingly or unwillingly, to do the bidding of politicians intent on more personal/political power and control. Cloaking themselves in the purest righteousness, of course, all for our own good.

    By Anonymous Anonymous, at 11:34 AM  

    Pay for performance is just an economic construct. I don't see any moralizing in it at all. The gov't wants doctors and patients to hit certain targets (which at times seem quite unreasonable, but that's a different problem). The fact is that having relatively normal BGs, or receiving aspririn post-MI doesn't make one more virtuous, it makes one cheaper to insure. (And healthier, too, but that's just part of the goal).

    I see public health as an entirely different entity from Medicare. Medicare at least confines itself to people who are actually ill. Public health targets the potentially ill- which is pretty much everyone. Historically, public health dealt more with environmental problems, but since those have largely been dealt with, the only thing left are behavioral ones. Hence the moralizing. It's much more clear how to deal with bad drinking water than bad behaviors.

    By Anonymous Danie, at 8:33 PM  

    Reminds me of the neighborhood committee where I grew up. People with far too much time on their hands caring about trying to dictate the lives of others. The sad part about this is that normally it's one or two people leading the bunch. Normally through fear and intimidation.

    By Anonymous Dara, at 10:49 AM  

    Actually, the cost savings from these measures are far from clear. Keep in mind that we are not taking about cost-effectiveness measured in the cost of QALY but actual savings. But while some measures may be cost-saving (e.g. blood sugar control of diabetics), other measures cost several times more than they save -mammograms or statins for primary prevention (especially if they are overprescribed as they often are) are prime examples.

    When claiming cost savings from popular preventive measures, politicians and even some doctors often forget to factor in NNT/NNS, false positive evaluations and overdiagnosis in case of screening or the fact that an ill person who is not taking his medication may die sooner and save money in many years of care. They also forget the cost of the bureacracy itself.

    Even cost savings from behavior changes are not that obvious. An obese woman who starts exercising may end up having injuries, for example. A person who fails to loose weight after trying may also end up consting more in healthcare.

    If P4P goal is to reduce costs, that maybe doctors should also ensure that their patients don't engage in any activities that result in excessive number of injuries - diving, running, gymnastics, figure skating, motorcycle riding, etc. Maybe the government should keep track of this is well?

    I am a bit scared of this whole idea as I think it has a potential to interfere with our right to refuse treatment or even make truly informed decisions.

    By Anonymous Diora, at 11:04 AM  

    you pretend that doctors aren't already tyrants, but every chronic pain patient knows better. i haven't met a doctor yet who has the ethics to put my quality of life before theirs...

    By Anonymous Anonymous, at 12:36 PM  

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