The Ethics of Medical Luddites

I'll join Micha in trying to break the Scott Scheule juggernaut.

Via Kevin MD, robot doctors and tele-medicine hold promise to revolutionize medicine:

Such robot-assisted exchanges are being repeated in dozens of hospitals across the country by doctors who use the machines to make their rounds, monitor intensive-care units, respond to emergency calls and consult with other physicians.

Proponents say this and other new "telemedicine" technologies are allowing doctors to use their time more efficiently and serve more patients, often at odd hours or in remote places where the sick would otherwise have a hard time seeing a doctor.

"There's a tremendous amount of medical care being provided from a distance today through technology like this," said Jonathan Linkous, executive director of the American Telemedicine Association.

Of course, you can always find a "bio-ethicists" to find a problem with every new piece of health and medical technology:

Skeptics, however, fear that the technology is further depersonalizing health care, accelerating the trend of doctors spending less and less time with their patients, and eroding what remains of the doctor-patient relationship.

"This is a triumph of the model of medicine that has abandoned the idea of personal interaction and providing comfort in favor of a model of the patient-physician interaction as essentially an exchange of information," said David Magnus, a Stanford University bioethicist. "You can see a face, but there's no touch, no laying on of hands, no personal contact. We're increasingly isolating people in a sea of technology."

The goal of the medical industry is not, and should not be, to have wonderful patient-doctor relationships, or to bring the community closer together. It's goal is this, and only this: to treat as many patients as efficiently as possible and to make as all as healthy as possible.

When faced with the technology profiled above, a bioethicist should ask not if it improves a patient's and his doctor's relationship or allows for more time spent together or whether there is actually physical contact. He should ask the question to satisfy the only ethic that really matters: Does this technology improve or worsen the health of patients? Ethics that foresake the latter for the former are ethics I want no part of.

Share this

While I agree that

While I agree that innovation in medicine is a good thing, I will take issue with your statement:

"[The medical industry's] goal is this, and only this: to treat as many patients as efficiently as possible and to make as all as healthy as possible."

The medical industry's goal is to maximize profits. They can accomplish this by treating as many patients as efficiently as possible, but it is arguable as to whether making us as healthy as possible helps them reach that goal. After all, if we are all perfectly healthy, we have no need for the medical industry.

It is a personal goal of mine to be as healthy as possible, but the medical industry is a last resort in my pursuit of that goal.

Again, I think that you

Again, I think that you might be missing the point here. I don't see that Magnus is saying anything that you're not. Indeed, I'm pretty sure that he's _not_ saying what it is that you're attributing to him. You have him asserting that he doesn't like some technology regardless of whether or not it makes people better. Nothing that he says indicates that that really is his position at all. Far from offering a reasonable interpretation of his argument, you've offered a complete straw man. And yes, I did the same to your position; I thought perhaps you'd see the connection.

Magnus' underlying assumption, I think, is that having a certain kind of relationship between a doctor and a patient is in fact necessary for the overall health of the patient. Any reasonable reading of the quotation you offer would, I think, recognize that. We can, of course, disagree about the truth of that assumption, but it is pretty clearly what is driving Magnus' worries. Understood as such, Magnus' point is perfectly reasonable: if X is necessary for health, and strategy Y completely ignores X and Z is a product of strategy Y, well then Z may be a bad thing. There are lots of claims there that we can disagree with, but the argument is not the wacky "I don't care about making patients well" claim that you attribute to Magnus.

Your (apparent) contempt for bioethicists seems to have led you to a pretty uncharitable interpretation.

_[The medical industry's]

_[The medical industry's] goal is this, and only this: to treat as many patients as efficiently as possible and to make as all as healthy as possible._

Magnus' whole point is that the first part of this goal may be inconsistent with the second part. That is, some technology might enable doctors to treat patients more efficiently without actually making them any healthier. Doctors could, for instance, get really good at treating symptoms without getting at underlying diseases because, say, they haven't spent enough time with the patient to really understand the ways in which all the symptoms are linked.

“Bioethisists” They

“Bioethisists” They seem to be everywhere nowadays. It is good that we have them because there have been serious bioethical lapses. That said, there are two troubles with them or any ethicists,- potential for egoism and lack of expertise. There is the automatic assumption that ethics has an automatic primacy over every other consideration. To advocate otherwise is to advocate the unethical, an untenable situation. The better course is to get a different ethicist that supports your position, which is usually pretty easy.
I think ethicists, because they are looked upon as final arbiters can become swell headed. I think ethicists only position should be as honest brokers, not pontificators. In fact they are not real experts in the fields they arbitrate. For example, they are not doctors who sometimes stay up all night caring for sick patients, soldiers who fight or even plumbers who lay in leaking sewage under your house. Not to be categorical, but some of what they write is a bit too ivory tower for me.

I think Magnus is

I think Magnus is misapprehending the causes of the disappearance of "what's left of the doctor-patient relationship." People are a lot more mobile now - even moving to a new house in the same metro area can put you a multi-hour drive away from your current doctor (at least in Atlanta). I've never had a "primary-care physician" in my life. I went to the same dentist for a long time, but gave up on that when a) the practice changed hands 3 times in as many years, and b) I moved to the opposite end of town.

From my point of view, I would love a medical industry that placed more of an emphasis on efficiency: right now it's such a pain in the ass to find a reasonably nearby doctor of the right speciality who's covered by my health insurance medical plan, play phone tag with his/her receptionist and negotiate an appointment, then take half a day off work at a minimum to sit in a waiting room until the doctor can actually see me, that even though I do have pretty good health insurance medical coverage, I just let most things that aren't a direct threat to life or limb go untreated, e.g. illness that lasts less than a week, ingrown toenails, chronic heartburn, etc. I'd like to get medical attention and reduce the amount of misery these things cause me (especially since my employer pays for most of it and I don't like my employer anyway), but the way things work right now, the opportunity cost, the disruption to my life, is just too high.

Bottom line: having a personal relationship with one's doctor has, for a lot of people, gone the way of having a regular corner grocer or milkman, simply because of societal change.

Before I am wrongly

Before I am wrongly construed as disparaging all ethicists and bioethicists and people pile on that cause - I was only meaning to disparage the ethicist in question.

Where's Wilde on this

Where's Wilde on this thread? I get the impression that Trent has not had a serious medical ailment (my apologies if he has.) Being treated for a serious condition is nowhere near as straightforward as it may seem and actually can involve the patient making several difficult choices which are heavily aided by a caring and patient doctor who can explain things in layman's terms.

Before I am wrongly

Before I am wrongly construed as disparaging all ethicists and bioethicists and people pile on that cause - I was only meaning to disparage the ethicist in question.

Every time I hear a "bioethicist" quoted in the news, he's saying something utterly reprehensible. Which ones don't deserve disparagement?

Matt, what does that have to

Matt, what does that have to do with anything? Are you even posting on the right thread? Patients have to make difficult choices that require doctor's to be able to explain things in laymen's terms? No shit.

Find anywhere I have said otherwise. I merely am celebrating technology that allows patients to be treated who may have not been treated otherwise (and criticizing those who think this is a bad thing). If that means we change the Dr-Pt relationship significantly but that it ends up being good for the patients overall, well, so be it.

find anywhere I've said

find anywhere I've said otherwise

Are you posting on the right thread? you wrote that the "goal of the medical industry" is not to have "wonderful doctor patient relationships" but rather to treat "as many patients as efficiently as possible." It sounds like you're preferring an "assembly line worker" doctor to an Artisan doctor. So, when I defended Dr-Patient relationships from your quite explicit attack, yeah I was posting on the right thread.

Brandon, _Every time I hear

Brandon,

_Every time I hear a “bioethicist” quoted in the news, he’s saying something utterly reprehensible. Which ones don’t deserve disparagement?_

And every time I see a "libertarian" quoted in the media, he's saying something idiotic. Of course what you see on the news will sound as if it's lunacy. It's often pretty hard to give context to serious, difficult issues in a 9-second soundbyte. And it's not as if journalists have lots of incentive to pick the _least_ controversial parts of an interview.

Before dismissing an entire profession, it might be nice to base one's opinions on, oh, I don't know, maybe some actual reading instead of whatever one picks up from CNN.

Maybe you could start with Jim Childress and Tom Beauchamp. Or Art Caplan. Or John Arras. Or pretty much anyone from the Hastings Center (www.thehastingscenter.org).

Again, saying that this is

Again, saying that this is not medicine's primary goal (which is what I said) and saying that the Dr-Pt relationships are a bad thing (which I did not) are two totally different things.

One last time: I'm merely making the point that if your reverence for the Dr-Pt relationship gets in the way of actually caring for the patient (which it admittedly rarely does - cases like the above are rare), then that is a bad thing. Anybody object to that?

Trent, Of course no one

Trent,

Of course no one objects to that--including, as far as I can tell, Magnus. My objection is that he hasn't said what you claim he says, not that your (more carefully done in the comments) hypothetical is false.

Again, Magnus seems to be disputing the antecedent part of your hypothetical, not denying the hypothetical itself. Obviously anyone who disputes the entire hypothetical is espousing something odd. I just don't see any evidence that Magnus falls into that category.

Trent, you should edit your

Trent,
you should edit your post if that's your point because that's not the point you make in the post. Your language is quite strong: The medial professions's "goal is this and only this" you write. Since you clearly consider Dr-Patient relationships as seperate from the "only goal" of treating patients as efficiently as possible, then you are clearly indicating that you don't think good dr patient relationships should be a goal. That just logically follows from what you wrote, bro. I'm sure you probably got caught up in your own rhetoric, and if you weren't being such a dick abut this whole thing it'd be easier to just let it slide.

matt

It's rather difficult to

It's rather difficult to glean anything from the quote, so far as I can tell.

This is slightly more illustrative:

http://www.wolfmanproductions.com/magnus.htm

Also, a paper by Magnus, et al, on the morality of eugenics:

http://bmj.bmjjournals.com/cgi/content/full/319/7220/1284

The latter sounds rather interesting.

Matt, there is no need to

Matt, there is no need to edit my post. I can be quite strong and say that X is Y's goal, and then consistently say that although Z is not Y's goal necessarily, it is beneficial to have Z to the extent that it supports X. Still, again, Z is not Y's goal. In the rare occasion that Z acts counter to X, then we should forget about Z.

Joe's more substantive criticism is that I should be more charitable to Magnus. First, we will probably agree that the competing interpretations are the only two viable ones - either a) he thinks the technology is bad or b) he thinks it's good but has bad qualities that we should at least understand. I go with A; Joe with B. I suppose he could have been more qualifying and the nature of journalism did not allow him to get in his whole statement (B). Fine. However, words like "abandonment" and "isolation" have very negative connotations (especially in their respective contexts) with me and make me lean strongly toward A. I'll at least concede that it's no sure thing.

the operative word is "only"

the operative word is "only" as in "only goal." If you say that x should be the "only goal" of y that excludes all other goals. That means, converting this back to the example we're discussing, you're saying that doctors should not set the achievment of a positive doctor patient relationship as a goal. That is simply what you are saying, and if that's not what you mean then you should edit your post.

You obviously just wrote this blog entry in a flurry of hotheadedness, lashing out at ethicists and saying doctors shouldn't try and relate to their patients. It happens. On a more positive note, I only noticed one quasi-insult to me in your last post (that Joe's comments were "more substantive") which may indicate that you're cooling down. cheers.

It wasn't a complaint; it

It wasn't a complaint; it was joke.

define terms all you want,though I'm not quite sure which terms you're talking about. How about, in the interest of compromise, I use your analogy about walmart:

it's true of course that the goal of Walmart is to make a profit, in fact they are legally bound to the "goal." That is a descriptive and true statement. We are talking about prescriptive statements, however. If you wrote that the "only goal" that Walmart "should" have is to make a profit I would disagree with you and make an argument to the contrary just as I did above. If you aren't equipped to defend such a statement then I would suggest that you withdraw it, just as I suggested above. The problem was that you didn't respond to my critique but rather denied you were even making the point, implying that I was posting on the wrong thread or something. Again I'd encourage you to defend your statement that Doctor's should never set as a goal a positive bond with their patients or withdraw it. Let's stop this circular nonsense.

So do I reply and engage in

So do I reply and engage in "circular nonsense", or not and appear not "equipped to defend such a statement". What a quandry.

How about this: Doctor's should never set as a goal a positive bond with their patients to the extent that it does not satisfy their goal of treating as many patients the best they can (maximizing health, as it were). It just so happens that acheiving this most often (or, almost always) maximizes health. Though, in this rare instance, they conflict. Thus, when fostering the traditional view of Dr.-Pt. relationship does not maximize health, it (and any analogous thing) should be discarded, leaving, when all is said and done, the only goal left that is worth anything: "To treat as many patients as efficiently as possible and to make as all as healthy as possible."

The End

You obviously just wrote

You obviously just wrote this blog entry in a flurry of hotheadedness

Curious. If it's so obvious, how come, in fact, I did not write "this blog entry in a flurry of hotheadedness"?

Also, any complaint about "quasi-insults" should be balanced asking the questions: who called who "a dick"? who is casting aspersions on the state of mind of the other? who extrapolated from a paragraph to guess my pesonal medical history? All insulting and apart from the issue at hand.

As to the point about goals: Wal-Mart one and only goal is to make a profit. There is no goal to create jobs, but they do it to the extent that it helps them make a profit. But no one can validly say that their goal is "to create jobs".

More generally, the beauty of writing something is that you get to define the terms (within reason). My definitions may differ from yours, and that's fine, but in trying to understand what I'm saying, you have to defer to my definitions, not the other way around.

It's funny. You say I

It's funny. You say I misrepresented Magnus when I gave a reasonable iterpretation of the only thing we know about him. On the other hand, you seem to want to try to represent my vision of the future of medicine as a scene from Bladerunner, when I clearly said nothing of the sort.

He said: "We're increasingly isolating people in a sea of technology." If X technology does isolate people but makes them healthier, is that good or bad? It's bad only if you value the relationship more than you value the health, which is a strange ethic if you ask me. If X makes people isolated and makes them unhealthier, then it is bad, but not because of the isolation; it's because it makes them unhealthier. You see, then, the merits of X technology can now be judged only by the criteria of whether it makes patients healthier, regardless of the effect on the relationship. And if the relationship is so important, as you seem to think and as it may well be, then this importance will show up by evidence that the patients are unhealthier.

agreed.

agreed.

Well, I would argue that

Well, I would argue that Magnus is assuming it as a settled empirical question in the opposite direction, based on the words he chose (though you may disagree). Can I treat him like an ethical moron then?

I should add that my personal experiences with telemedicine have shown it to be nothing but beneficial. My med center is the tertiary med center for all of the poor Appalachian region of KY; telemedicine is all the rage here, and most people who use it may not get adequate care otherwise.

Trent, _Doctor’s [sic]

Trent,

_Doctor’s [sic] should never set as a goal a positive bond with their patients to the extent that it does not satisfy their goal of treating as many patients the best they can (maximizing health, as it were). It just so happens that acheiving this most often (or, almost always) maximizes health. Though, in this rare instance, they conflict._

This is still begging the question. The entire dispute, it seems to me is whether this really is a case in which efficiency and maximizing health coincide. That's going to be an empirical question that isn't at all resolved in the exchange that you reprint at the top. Your strategy, instead, is to treat the empirical question as settled and then attack Magnus as an ethical moron for endorsing a position that, rightly enough, would be lunacy to endorse. But that interpretation makes sense _only_ if we assume that the empirical question is settled. Magnus surely would dispute that it is settled.

Trent, If the empirical

Trent,

If the empirical question is settled in the opposite direction, then Magnus' claims would actually be correct. That wouldn't make him an ethical moron at all.

You might well argue that he doesn't know what he's talking about on the empirical question. You're in a far better position to argue that point than I. But to the extent that it is still an open question, one can then make moral arguments about the desirability of the practice based on yes or no answers to the empirical question. The correct moral agument, then, will turn on the correct empirical answer. Either way the empirical question turns out, though, a moral argument based on the wrong answer isn't indicative of some sort of lapse in moral judgment, as your initial post implies.

The only way that your interpretation of Magnus can be the right one, as I see it, is if (a) the empirical question at issue is settled, (b) the answer to that question is the one that you favor rather than the one that Magnus favors, (c) Magnus accepts that yours really is the correct answer to the empirical question, and (d) Magnus continues to endorse the moral argument he gave based on his (incorrect) answer to the empirical question.

It seems to me that (a) is likely not met, (b) is still an open question, (c) is certainly not met, and (d) cannot be met (since it would require that (c) first be met). So to sustain your reading of Magnus, you're going to have to show _way_ more than you've done thus far.

The correct moral agument,

The correct moral agument, then, will turn on the correct empirical answer.

Ah hah! There we have it. I'll be the first to admit I don't express myself most eloquently. Magnus was taking the ethical position without making an inkling of an empirical argument to the overall effect of health care (in his two paragraphs in a news article). That's what I meant in my last comment that he was guilty of the empirical assumption.

The ethical argument swings 100% on the empirical outcome, and platitudes about relationships are irrelevent without evidence that the overall outcome is bad (which he did not give).

Of course, I assume the empirical question, but I feel that is a valid assumption. My mistake was not relaying this information of my experience from the get-go, in which the reader might have been more convinced that my assumption was valid.

Judging only from the quote

Judging only from the quote given above, I'd have to go with Dr. McBride's interpretation. Concerns about the efficacy of a particular technology isn't what drives people to utter silly platitudes like "We’re increasingly isolating people in a sea of technology." Yes, he may have been quoted out of context, but I have serious misgivings about the mental fitness of someone who would say that in any context.

That said, someone who's willing to defend eugenics can't be all bad.

Trent, What's with putting

Trent,

What's with putting 'bio-ethicists' [sic] in scare quotes? Should I respond by talking about "doctors" who, after all, stole the title from real doctors a couple hundred years ago in order to give themselves a bit more cachet?

Leaving aside the snideness, though, I wonder whether you haven't pretty seriously misinterpreted Magnus. Maybe he really is a Luddite who prefers not to endorse any new technology. I haven't read anything he's written other than the single quote you give. I don't know many bioethicists who actually dislike technology on principle, though plenty of them dislike _certain_ technologies.

Still, I'm not sure how it is that anything Magnus says in this little quote commits him to the view that you ascribe to him. In talking about having a certain kind of relationship between doctors and their patients, I suspect that better and more efficient health care is exactly what Magnus has in mind. Maybe this has gone out of fashion with new doctors, but my understanding is that the idea behind developing an actual realtionship with a patient is that it provides doctors with better insight into the overall health of a patient, making it more likely that one can treat underlying problems rather than just responding to symptoms.

The sort of medical care you seem to have in mind is the type where you bring in a sick body, hook it to some machines, get a diagnoses, and then offer it a pill or hook it to more machines. Maybe that will turn out to be the most efficient way to go, though I suspect that we're not there yet. Still, it does lead me to wonder when the rest of society will realize that "doctors" are mostly just body mechanics and adjust their attitudes (and checkbooks) appropriately. :razz: