THCB

Iconoclasts and Healthism

An iconoclast must not only have abundant common sense but the gift of the gab to state the obvious. Simply stating won’t do. You must rub it in.

My favorite iconoclasts are Peter Skrabanek and Thomas Szasz. Skrabanek was a general practitioner who authored Death of Humane Medicine and Rise of Coercive Healthism. Szasz, a psychiatrist, who volunteered that he entered psychiatry to unveil its pseudoscience, is the Voldermort of psychiatry – he who must not be named (may be Voldermort is the Szasz of muggles). He wrote several books including “Myth of Mental Illness.”

Neither believed in nominative subtlety. The title of their books gave it away. Both Szasz and Skrabanek had a point. The point was simple. Be careful. Don’t allow the medical profession to medicalize the broad coastline of normality – the dog ears of the bell-shaped curve.

Skrabanek was a socialist, Szasz a libertarian. Neither was against medical care for the sick and poor. Skrabanek was urbane, Szasz went for the jugular. Both were prescient. They predicted modernism’s medical epidemic: overdiagnosis.

I’m a pseudo iconoclast. I look for real ones. I recognize them a mile off. They are straight shooters. They are humane but do not wear sentimentality on their sleeves. So it was not hard to spot Vikram Khanna, the author of Your Personal Affordable Care Act. Khanna is an ‘in the trenches’ foot soldier who has worked on the wards, worked with insurers and worked as a regulator. He has a mission, like Skrabanek who he worships. To fight healthism.

Healthism is not the promotion of health but the medicalization of everyday life in the pursuit of perfect health.

It starts with a simple logic. If we catch disease early we will prevent complications. True, if we know who has early disease that will progress. But we don’t. We have to cast the net wide, wider the earlier we want to intervene. The trouble is when we throw the net we accuse innocent bystanders of a disease they never were destined to have.

Healthism is collateral damage for our preemptive strike.

Khanna blames the medical establishment for healthism. He has a point – up to a point. Physicians have internalized medicine’s inherent limitations as their personal failings. That’s the easy part, to say we suck, whilst drawing our pay check. It is an odd self-flagellation that is not only morally pleasing but financially rewarding. Buddhist Lamas fast when they transgress. We feast.

The difficult part is to articulate our imperfections. To admit we don’t know. To say that it is better we stick to the sick rather than prod our stick amongst the healthy in the hope of finding the sick. To say, yes I missed that your vague chest pain was because of aortic dissection but were I to have flagged it, I’d have to flag a thousand others who don’t have aortic dissection and, quite frankly, society doesn’t have the resources for that. That requires intellectual and moral courage. Tortured introspection is easier.

But is it better that one sick person is not diagnosed early than ten healthy people are falsely labelled with disease? I am not sure

It takes two to tango. The public doesn’t want aortic dissection to be missed. Death from aortic dissection is avoidable because it is treatable. Avoidable and preventable are two of the most capacious words in the medical lexicon. They can’t be unproven. They have propped up industries. The public has consented to healthism, implicitly. Because one person’s avoidable is another person’s overdiagnosis.

Khanna meets midway. He urges Americans to run, to exercise, to eat judiciously. He pithily advises “eat less, eat less crap.”  If people look after themselves they will avoid the physician and defer the grim reader. He internalizes avoidable and preventable, not by placing the onus on the medical profession, but on the individual.

He is a rugged individualist, a determinist, a Calvinist. If you smoke you must pay. You should not diffuse the costs to those who chose not to smoke, he opines.

I agree with Khanna –to a point. Personal responsibility should be encouraged. But irresponsibility should not be punished. To what extent will you punish irresponsibility? Will you ask bungee jumpers to pay for their detached retina whilst covering Whipple’s procedure for fitness freaks who have the misfortune of pancreatic cancer? Will you not cover a person’s injuries if attacked by a Grizzly bear whilst hiking in Yellowstone National Park because they should have known better and stayed at home?

Propensity for risk is the tapestry of our society. Some climb Everest. Some smoke 20 cigarettes a day. Let it be. Freedom lies in not fretting over your neighbor’s cholesterol and how it might impact your insurance premium. Freedom lies in letting it go. Freedom costs. Healthcare costs are higher in a free society precisely because idiots are free to do what they want to do.

Khanna is right but Skrabanek is really right. The job of doctors is to heal the ill not hound the well. We can cure the pathology of the body not the pathology of society. Let’s keep it that way.

Saurabh Jha, MD is a radiologist at the University of Pennsylvannia. His opinions do not reflect the views of his employer. 

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45 replies »

  1. “Propensity for risk is the tapestry of our society. Some climb Everest. Some smoke 20 cigarettes a day. Let it be. Freedom lies in not fretting over your neighbor’s cholesterol and how it might impact your insurance premium. Freedom lies in letting it go”

    So I’m letting it go.

    Amy Kramerr
    http://www.ecigexpert.com

  2. This is probably one of the most important element of khanna’s viewpoint : Personal responsibility should be encouraged whether healthcare, dentalcare…. It leads to the freedom and the power to influence on our health… in both ways….

  3. “just whisper.”

    None

    “Enlighten me oh wise troll”

    “We know little of the things for which we pray. ”_G.C.

  4. “Your problems focus on your difficulty with the marketplace, how insurance works and the conversion of your license from M.D. to officer of the state.”

    Enlighten me oh wise troll 😉

    Save me before I become swallowed by the leviathan!

    Meanwhile, if there is any government entitlement you want me to safeguard, just whisper.

  5. “Enlighten me.”

    Once again you are going astray. Your problems focus on your difficulty with the marketplace, how insurance works and the conversion of your license from M.D. to officer of the state.

  6. “If you understand insurance and market places as well as you think you do then you would be stumbling all over the answers.”

    Enlighten me.

    Warranty on what?

  7. “Well we have a different definition of “disarm.””

    No, you chose a different definition of disarm. The used car market was an example of information asymmetry where market forces prevailed in the form of the warranty.

    “Why would patients not wait until they are sick to purchase insurance?”

    Once again you create your own definitions as to the direction of the discussion. If you understand insurance and market places as well as you think you do then you would be stumbling all over the answers.

  8. Well we have a different definition of “disarm.”

    Akerlof used car market was about asymmetric information.

    Why would patients not wait until they are sick to purchase insurance?

    How would you persuade the healthy to purchase insurance?

    Warranty on what?

  9. Earlier I disarmed your lemon with a warranty (Akerof’s lemon, a used car). Let us get back to the real question, what insurers in a free market can do and your inability to rely upon free market principles converting the physician into an officer of the state.

    [Akerof Nobel Prize winner on information asymmetry and ‘bad driving out good’. His example was the used car industry, but the marketplace has an answer, a warranty.]

  10. “officer of the state”

    Fear not allan, I pledge to keep the government’s hands off your Medicare 😉

    Now back to my original question.

    How will you solve the problem of lemons? (see Akerlof)

  11. Don’t blow a gasket because of your refusal to understand that traditional insurance isn’t dependent upon your lack of knowledge on the subject, your Harry potter fantasies or your philosophy of life. Though you have indicated your libertarian leanings I note that in healthcare you apparently wish to change the role of the physician from being the servant of the patient to becoming the servant of the state.

    As long as you maintain that philosophy you are no longer a physician, but an officer of the state.

  12. “If you think otherwise let us know.”

    JHC, allan it’s like reading 7 books of Harry Potter and asking who is Lord Voldermort (this is not an example of a strawman argument!).

    Did you miss this line?

    “Insurance would collapse if entirely voluntary, because of the problem of lemons.”

    You replied to it so I assume you read it.

    Of course, I think otherwise! That’s why we’ve just had 8 posts exchanged!

  13. “The fact is that traditional insurance can statistically manage both health and fire issues without entering into a death spiral whether or not you wish to admit it.”

    Je suis allan!

    I defend to death your right to be evasive, to assert and to have your propositions protected from critical thought.

    If anyone dares to get allan to think on this thread they have me to answer to!

  14. I would include Nortin Hadler Professor of Medicine at University of North Carolina at Chapel Hill….
    Two of his books: The Last Well Person and Citizen Patient well display his iconoclastic bona fides.

  15. The question was asked and answered. If there is a specific context to your question spell it out.

    The fact is that traditional insurance can statistically manage both health and fire issues without entering into a death spiral whether or not you wish to admit it.

    If you think otherwise let us know.

  16. “Your question is not relevant.”

    Of course it’s relevant and you know it is relevant, which is why you refuse to answer it, instead cloaking in some “philosophy.”

    In the rare event that you don’t understand the relevance, which I highly doubt, here it is.

    Illness is a much greater certainty than fire.

    Understanding this means you will understand that the fact that fire insurance hasn’t undergone a death spiral does not mitigate the same happening in voluntary health insurance.

    This is not philosophy or ideology it is basic actuarial statistics.

  17. Though I feel fairly certain I understand the direction you are taking, I am not going to interpret your philosophy when answering a question unless you wish to phrase the question so that your philosophy behind the question is revealed. Only then another can take on the question and the philosophy at the same time. Anything else is game playing.

    “Are the chances of an illness higher or lower than the chances of a fire, in an individual’s lifetime?”

    Your question is not relevant. Traditional insurance can manage both health and fire issues.

  18. I love Skrabanek. I think he is the closest intellectual cognate of Vik and Al.

  19. “Is there a death spiral in the fire insurance market?”

    I’m keen to resolve this.

    Are the chances of an illness higher or lower than the chances of a fire, in an individual’s lifetime?

  20. The whole idea behind classical insurance is uncertainty and unpredictability.

    Premium and time intervals are essential items. Have you not heard of life insurance?

    Health insurance insures for illness, not death.

    One has to differentiate between charity (forced or otherwise), pre paid health insurance and health insurance in the classical sense.

  21. “Is there a death spiral in the fire insurance market?”

    Correct.

    But you must know that the need for healthcare is not as uncertain as the occurrence of a fire.

    Death is a certainty. Fire is not.

    How will you resolve this?

  22. Do you presuppose that a person is permitted to buy fire insurance after a fire burns down his home? “Imagine if people bought insurance only when they needed to” …”What would happen to the insurance market?”

    Is there a death spiral in the fire insurance market?

    What part of “There is no reason for insurance to collapse with a voluntary system that arises in the marketplace.” do you think needs explaining in the context of our discussion?

  23. “consuming about as much of it as people in other places – sometimes consuming less of it.

    Not sure about that.

    But I never said, and I don’t believe, the healthcare system here enhances freedom.

  24. “How else can we find what is going on with the 60 or so genes that are associated with autism or the dozens associated with most cancers?”

    You’re correct.

    Then one must accept that overdiagnosis is precision medicine’s collateral damage.

  25. Good analogy.

    We eat when we are hungry – i.e. when we need to.

    Imagine if people bought insurance only when they needed to, that is when they are sick. What would happen to the insurance market?

  26. “Healthcare costs are higher in a free society precisely because idiots are free to do what they want to do.”

    Not sure the evidence on prices supports your hazy ideological summary.

    Americans pay higher prices for care, consuming about as much of it as people in other places – sometimes consuming less of it. Freedom seems to have aught to do with it – unless by ‘freedom’ you mean ‘asystematic approaches to treatment pursued by physicians in stubborn isolation’.

  27. “the content of the book I have read so far seems very akin to a medical version of Hayek’s The Road to Serfdom”

    whew, thanks for scanning the thing and saving me that 5 minutes of my life.

    I wonder if VIk Khanna actually swats gnats with ballpeen hammers, the way his writing about health care suggests he might

  28. We can’t just focus on who looks sick or feels sick or who tests sick. We have to sometimes work with the mode of the bell shaped curve, smack dab with the wellest. How else can we find what is going on with the 60 or so genes that are associated with autism or the dozens associated with most cancers? or mental diseases? Big and glorious medical revolutions may have to add or subtract large components of our environment or our epigenomes or even our genomes to get the dreams that the public has of splendid health. Something bad is happening to us all if one in 69 has autism or spectrum disease and one in eight women are getting breast cancer.

  29. This can be read as yet another take down of the current (sad) state of the so-called wellness industry. Over-screening, misdiagnosis, HRA’s. Talk about medicalizing life.

    The only wellness I see coming out of their efforts is the wellness companies revenue.

  30. Not even the act of eating is entirely voluntary.

    If we don’t parse words to the extreme one recognizes that most insurance is voluntary. There is no reason for insurance to collapse with a voluntary system that arises in the marketplace.

  31. You are right. I stand corrected.

    God knows who I was thinking of when I called him a socialist!

  32. Thank you for referencing Petr Skrabanek….having just scanned some of his Death of Humane Medicine it is as if he is writing about all the foundations of the ACA.

    In the forward of the book the editor of Lancet appears to characterize Skrabanek as a libertarian, not a socialist as you call him…..the content of the book I have read so far seems very akin to a medical version of Hayek’s The Road to Serfdom.

  33. “Can’t we mess around with health care and have some fun, just as we did with build-your-own airplane kits in the 50′s.”

    “Oh I know, do it on your own dime, bucko.”

    You said it!

  34. It’s a nice distinction (force vs. voluntary).

    Insurance would collapse if entirely voluntary, because of the problem of lemons.

  35. Oh, I heard free a few times: Free yearly physical, etc. We know what they meant, no added cost/copay to patient, but not free. And if they find something? All bets are off.

  36. Yeah, but I somehow missed the part where Obama said it would be free. We have the right to military defense, but, Lordy, is IT ever not free.

  37. ” President Obama speaks of access to healthcare as a “right,” but the problem is that rights without responsibilities are just entitlements.”

    Bingo!

  38. I like Vik’s book. I like the premise.

    I like Vik. He’s solid.

    An alternative Affordable Care Act based on personal responsibility, common sense and a lot of heavy duty research.

    I think we’ll be seeing a lot more of Vik once word gets out

  39. I love the above discussions, but isnt it too early to tell? I.e. too early to decide what to treat? I would like to know where all the 40-80 mutations are coming from behind most cancers? How are we getting these? Can’t we play a
    little in health care and fool around elongating our telomeres and maybe acquiring some youth therefrom? How about a treatment that rips off some epigenetic methyl groups from DNA and histones and gives us some more stem ES cells to charge our old batteries? Or removes DNA oncogenic adducts?
    Can’t we mess around with health care and have some fun, just as we did with build-your-own airplane kits in the 50’s. Oh I know, do it on your own dime, bucko.

  40. Yes, but one could argue that the whole purpose of health care is to prevent everything and go home.

  41. “Will you ask bungee jumpers to pay for their detached retina whilst covering Whipple’s procedure for fitness freaks who have the misfortune of pancreatic cancer? ”

    One can ask, but should one force?

    Your emphasis appears to presuppose that the insurance pool paying for these things must be involuntary.

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