Thursday, March 15, 2012

The Cruelty of Medicine

Should the medical system be concerned with how people feel about their interactions with the medical system? "Patient satisfaction" with medical care has been tracked in recent surveys and studies, often with unanticipated results: for instance, patients with the highest reported satisfaction with medical care are more likely to use more medical care - and more likely to die. Are the feelings of patients something we should care about enough to measure and track? Or are they totally irrelevant?

Oncology nurse Theresa Brown argues in the New York Times that patient satisfaction is irrelevant. Beginning with a description of a horribly painful medical procedure known as pleurodesis, Brown argues that the most effective medicine is often painful.

Brown seems to understand that there is a trade-off between suffering and efficacy. But she does not seem to understand that patients might well wish to trade longer lifespan for less suffering. In fact, that is exactly what doctors facing terminal illness frequently do - avoid the painful, dehumanizing treatments that might possibly buy them more time, in order to enjoy the time they have left (or just to avoid prolonged suffering).

My problem with the medical system is that built into it is a core assumption that longer lifespan is the only concern - that there is such a thing as "health," and all other concerns are properly subjugated to this concern, except - perhaps - in cases of terminal illness. Brown says that "a survey focused on 'satisfaction' elides the true nature of the work that hospitals do. In order to heal, we must first hurt." Some patients may wish to go through painful procedures if it is the only way to prolong life; but this should not be the assumption in every case, and if medical professionals are surprised that people are unsatisfied with torturous-but-life-prolonging medical care, that demonstrates the depth of their bias. One wonders how the average psychiatric patient would rate his or her "satisfaction" with the "care" applied to him or her by force; but non-psychiatric medical care is not another kind of thing, but on a spectrum with psychiatric "care."

Humans have many concerns; one of them is often lifespan, but that is not the sole value that most people care about. I have noticed that many medical professionals are quick to defend awful, dehumanizing procedures on the ground that they save lives - even if the person being "saved" does not want the treatment. I think that measuring "patient satisfaction" is a sideways way of gauging the degree to which painful, degrading medical treatment is truly voluntary.

Our medical systems in the developed world are an arm of government, even where medicine is for-profit and not socialized. Doctors are given a huge amount of police power, such as deciding what treatments or drugs their patients are allowed to access. I suspect that a truly free market in medicine - one in which doctors were advisers only, and not cops - would result in both lower lifespan and greater "patient satisfaction" (happiness). That's only a bad thing if you think lifespan is the only goal, and that everyone should be forced to pursue it.


  1. Correct me if I'm wrong, but I think "patient satisfaction" generally measures for how well cared for people *feel*, and has little to do with objective (non-life-expectancy) effects, like pain. I have known many doctors, and I have never heard one of them express anything close to the attitude that life-expectancy is the only thing that matters.

  2. That's a helpful way to put it - indeed, I think "patient satisfaction" is a broad term for subjective measurements, including feeling cared for and well treated (high status?). But I'd definitely put pain in the "subjective" category.

    The bias I claim applies to the medical system is not necessarily one held by each individual doctor. But this helps me see that the bias in the medical system has two causes that reinforce each other:
    (a) objective stuff is easier to measure; subjective stuff is hard to measure.
    (b) being forced to take seriously subjective self-reports from patients erode the authority of the medical system to make patients do what it wants, including consume and pay for the services it wants.

    There are a class of objectively measurable effects that are not life expectancy; I wouldn't put pain in this category, but things like weight loss, wound healing, and a change in any other objectively measurable symptom could qualify. But "patient satisfaction" is not only about subjective stuff like pain, but about how much people care about the objectively measurable stuff. The medical system as an edifice may be characterized as requiring people to care about only certain things; but people care about a lot of things in reality, including things doctors don't care about.

    When I was in high school, I helped conduct research on the factors doctors versus patients consider when starting early AIDS drug therapy, and there were vast differences. Doctors don't care about the same things patients care about; I think this is a problem for the medical system, not just a sign that patients are stupid and need to get with the program.

    Your comments helped clarify my thinking - thanks!

  3. If I were something of a conspiracy theorist, I'd say it's another instance of the Life-loving cult enforcing their policies on us. But that's not strictly true. It's more the fault of untrue memes floating about in the heads of doctors since probably the beginning of medicine - of course 'Do no harm' could easily also be interpreted as immediately practicing euthanasia because the act of forcing a patient to suffer IS in fact doing harm. But I digress.

    Ultimately this environment, I think, is going to change sooner or later. Apart from among religious folk, euthanasia does seem to be propagating itself quite well as a meme. Like with genes, some memes survive over generations, there's a frequency change among memes, and then those memes that are inferior to the environmental conditions do not survive. (Which is all a useful thought experiment to give us some hope that eventually doctors won't be so evil, but not based on evidence at all).

    Doctors mainly don't care about the same things patients don't care about I'm thinking because patients feel indebted to doctors, and hence do what they say. This may actually be one benefit of private healthcare (among few in my book), since patients don't necessarily have as much 'respect' for doctors, who are service-providers, rather than philanthropic benefactors (even if they ARE still getting paid for it). There is also the feeling that doctors know more than patients, so of course spinal taps are in the patients' 'best interests' (because doctors say so).

    There is, finally, the horrible, horrible meme that suffering is a natural part of life, so should be endured, and may even teach you a lesson in humility. People also think that life is always worth living - even if they are for euthanasia, they may be against non-terminally ill suicide.

    I feel somewhat attached to this blog post simply because I am a person with a phobia of needles. Looking at needles injecting for long enough is enough to make me faint - actually being injected with something is enough to make me vomit AND faint. If I were being injected with things everyday and did not already have a deathwish, I would vote for euthanasia immediately.

    "Doctors are given a huge amount of police power" Especially psychiatric ones. 'Nuff said.

    So will things change? I am hoping that Euthanasia's legalisation (if it happens) will have a knock-on effect, BUT the other things I have said ultimately could block this effect from occurring.

  4. Interesting account of the only person known to have escaped from a North Korean prison/labor camp. In one part he excoriates his father for conceiving him inside the camp, and the father seems to acknowledge the wrongness of bringing people into such an existence but regards it as inevitable.

  5. Thank you, TGGP.

    In your blog, you say North and South Koreas were quite equal in 1970. It is important to note that: that means, we simply can't say, we live in France, or the US, and our child won't possibly be tortured.

  6. Online patient satisfaction survey allows you to check your patient`s satisfaction. Create patient satisfaction survey and track your patient`s health.
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  7. Typical of the medical prejudice in favor of length of life over quality of life is the goal of renal transplant therapy, which is that the patient not die with a functioning graft, but only after the graft has failed. But most patients would prefer to be dead rather than return to dialysis, yet medicine's stupid assumption that life is the only value prevents the patient's view from being heard.


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