By PRADHEEP J. SHANKER, MD

Sadly, the case of Alfie Evans came to a close this week, as he passed away in his hospital room surrounded by his parents. The debate over the medical ethics involved goes on.

Ultimately, there are extensive moral, philosophical, and medical issues involved with the policies over these cases. They are complicated, messy, and often times heart wrenching. But let’s put some misconceptions aside to begin with, some propagated by the most extreme and emotional participants in this debate.

Those of us that took issue with the handling of this case for the most part do not believe the doctors involved were evil, murdering individuals. There was no malicious intent from the NHS or physicians involved. I am sure the physicians meant well, from their point of view.

A second point: this was not a case about preservation of resources for the greater good. In this case, the parents had found alternative sources to fund the care they wished for their son.  So those arguing that we need to make such decision to prioritize money for those that can be aided the most is largely off target, and not relevant to the case at hand. I also don’t believe that the single payer system of the NHS in England inherently caused their mistakes; I think any system that is blind to its own deficiencies could lead to such mistakes.

That said, what were the issues that were in dispute here?

First and foremost, what was the ultimate intent of the care providers in this specific case?  Both sides basically admitted, early on, that Alfie’s prognosis was dire.  The reality is this child was likely going to die, and even the experts preferred by the parents readily admitted this in court documents.

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By SAURABH JHA, MD

Intrigued by many things in my first few days in the U.S., what perplexed me the most was that there seemed to be a DaVita Dialysis wherever I went; in malls, in the mainstreet of West Philadelphia, near high rises and near lower rises. I felt that I was being ominously followed by nephrologists. How on earth could providers of renal replacement therapy have a similar spatial distribution as McDonalds?

After reading Friedrich Hayek’s essay, Use of Knowledge in Society, I realized why. In stead of building a multiplex for dialysis, which has shops selling pulmonary edema-inducing fried chicken, DaVita set shop where people lived or hung out. It wasn’t a terribly clever business plan but its genius was its simplicity, its humility. If the mountain will not come to Muhammed, Muhammed must go to the mountain. DaVita went to the masses.

The link between Hayek’s wisdom and DaVita’s business plan may seem tenuous. But Hayek has been misunderstood, particularly in healthcare. Many a times and oft in the policy world Hayek has been rated about money and usances. This is because of a misperception that Hayek was all about profit and loss, which are anathema to healthcare. Hayek’s message was simple: local knowledge can’t be aggregated. From this premise sprouts others – dispersed agents in certain times and places possess fragments of knowledge which don’t come easily to central planners.

For Hayek, socialism and capitalism weren’t moral but epistemic issues. Socialism would fail because of a coordination problem – markets would succeed because they could use price signals to coordinate. Healthcare doesn’t use price signals to coordinate, not explicitly, at least. Nor does it capitalize on dispersed agents – on local knowledge. Hayek, a supporter of universal healthcare, didn’t specifically discuss healthcare in his essays. Nonetheless, it would be a useful intellectual exercise to speculate how Hayek might have applied his wisdom to modern healthcare.

What does local knowledge in healthcare even mean? Stated in a rather unlettered way, it is the provision of healthcare locally. AEDs are no good if they aren’t located where people congregate. The value of local presence of medical facilities, particularly in poor neighborhoods, is hardly rocket science. Just as great cities grew near rivers, great hospitals germinated in poor neighborhoods. But, with growing centralization of healthcare, with hospitals becoming multiplexes, futuristic cities with a distinct architectural phenotype, different from the neighborhoods they serve, the value of decentralization can be missed.

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By SAURABH JHA, MD

The good that doctors do is oft interred by a single error. The case of Dr. Hadiza Bawa-Garba, a trainee pediatrician in the NHS, convicted for homicide for the death of a child from sepsis, and hounded by the General Medical Council, is every junior doctor’s primal fear.

An atypical Friday

Though far from usual, Friday February 18^th, 2011 was not a typically unusual day in a British hospital. Dr. Bawa-Garba had just returned from a thirteen-month maternity break. She was the on-call pediatric registrar – the second in command for the care of sick children at Leicester Royal Infirmary. As a “registrar” she was both a master and an apprentice – a juxtaposition of roles necessary for the survival of acute care in the NHS. Because there aren’t enough commanders, or consultants (attendings), in the NHS trainees must fill their shoes or else the NHS will collapse.

The captain of the ship and Dr. Bawa-Garba’s supervisor, Dr. O’ Riordan, was not in the hospital but teaching in a nearby city. As horrendous as “attending not being in the hospital” sounds this, too, is not atypical in the NHS. Dr. Bawa-Garba’s colleagues, i.e. other registrars, were also away, on educational leave. Normally, a registrar each is assigned to cover the wards, the emergency department and the Children’s Assessment Unit (CAU). On that day, Dr. Bawa-Garba covered all three. She was new to the hospital, but with no formal induction – i.e. no explanation where things are and how stuff gets done in the hospital – she was expected to get along with the call and find her way around the hospital.

As anyone who has been a junior doctor in NHS can attest – the normal, the optimal, is unusual, and what is usual in British hospitals is remitting and relapsing chronic understaffing. The abnormal eventually becomes normal. You work through the anarchy. The anarchy is both the old normal and the new normal.

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By SAURABH JHA

According to the WHO definition of health, which is “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity,” several million Americans became unhealthy on Tuesday November 8^th, 2016 as Florida folded to Trump. As Hillary’s prospects became bleaker many more millions, particularly those on Twitter, lost their health. The WHO sets a high bar for health. It is easier for a camel to pass through the eye of a needle than for a person on social media to be in “complete mental and social well-being.”

Whilst WHO has set a high bar for health, modern medicine casts a wide net for disease, and the duo have led to mass over medicalization, overdiagnosis and overtreatment. Yet despite the wide net, Trump has thus far managed to evade the psychiatrists, medicine’s version of the FBI, who have tried imposing upon him a range of psychiatric disorders including “extreme present hedonism”, which sounds like “hyperbolic discounting,” which basically means someone who doesn’t give a rat’s tail about the future. Base jumpers suffer from this condition. I once suffered a milder version – and then I became a father and grew up.

Trump doesn’t look like a base jumper. And you’re going to need more than hyperbolic discounting to nail him on the 25^th Amendment. Some tried diagnosing Trump with “mild cognitive impairment” (MCI) – a condition which heralds the more persuasive cognitive decline of dementia. MCI reminds me of an old medical school friend who went around administering the mini mental test to elderly patients on medical wards. One of the questions was: what are the dates of the 2^nd World War (WW2)? No patient got that question right because my friend thought WW2 started in 1940. It started in 1939.

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By SAURABH JHA, MD

The two writers who got inside my head were polar opposites. Christopher Hitchens was an atheist, who mocked religion incessantly, and spared few sacred cows – he went after both Mother Teresa and Bill Clinton, though for patently opposite reasons. G.K. Chesterton, the sardonic, plump Englishman, went after heretics. Hitchens destroyed orthodoxy. Chesterton mocked radicals. Hitchens once quipped that “what can be asserted without evidence can be dismissed without evidence.” Chesterton quipped that the rebel, the infinite skeptic, was in fact a decerebrate orthodox. If both were on Twitter they’d be trolling each other, non-stop. Though fighting on opposite sides, they had a commonality – they punished sloppy thinking, one with prose and the other with wit.

I’ve long wondered who would be healthcare’s Hitchens and Chesterton. Physician writers have generally been disappointments, because they veer, almost uncontrollably, towards tedious self-flagellation, ever keen to internalize medicine’s original sin – an imperfect science, a stubborn art. Unlike prophets of yore who risked harm in expressing their views, medicine’s prophets moralize from the comfort of their six-figure salaries. “We do too much”, they say, even as they’re grass fed by the excess they so disdain – count me in this army of hypocrites.

For many years healthcare watchers have been fed a steady stream of Disneyland economics, trite platitudes, which have simplified the complexities of healthcare – cheesecake factories and checklists, value not volume, “we must do things for patients, not to patients” (needless to say that often to do things for patients you must do things to patients), amongst others. Whatever purpose platitudes are supposed to serve, they bring all critical thinking to a jerky end. I recall several talks during the passage of the Affordable Care Act in which the speaker would romp to a standing ovation for stating blithely – “let’s pay doctors for doing the right thing”, with me still muttering “how?”

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By SAURABH JHA, MD

The reactions of physicians to ORBITA, a blinded, randomized controlled trial (RCT) from Britain, with a sham arm, comparing percutaneous coronary intervention (PCI) to placebo, in patients with stable angina, are as fascinating as the cardiac cycle. There were murmurs, kicks, and pulsating jugulars. Though many claimed to be surprised, and many unsurprised, by the null results of the trial, the responses were predictably predictable. Some basked in playful schadenfreude, and some became defensive and bisferious.

No shame in sham

The coverage of the trial in the NY Times was predictably jejune and hyperbolic. Predictably, the most nuanced and divergent viewpoints were curated by Larry Husten. Predictably, medical Twitter was set alight. The trial vindicated Vinay Prasad and Adam Cifu who predicted that PCI for stable angina will get placeboed, in their popular book, Ending Medical Reversal. Prasad and Cifu are tireless advocates for using sham control trials to judge the true efficacy of procedures, such as PCI, in relieving symptoms, and reject the notion that invasive placebos are unethical. There’s no shame in sham, they say. They were right.

The Objective Randomized Blinded Investigation With Optimal Medical Therapy in Stable Angina (ORBITA) is an impressive trial, which enrolled 230 patients with stable angina and single vessel stenosis greater than 70 %. The vast majority had class 2 (59 %) and class 3 (39 %) angina. Majority of the patients, 70 %, had LAD lesions. If you look in the appendix, which has pictures of catheter angiograms of all patients, you’ll see scary tight proximal LAD stenosis – yes, even these patients had 50 % chance of getting sham. This takes balls. The trialists deserve applause, as do the Brits who volunteered. These were no snowflakes.

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By SAURABH JHA, MD

When Aneurin Bevan was asked how he convinced doctors to come on board the National Health Service (NHS) he allegedly replied, “I stuffed their mouths full of gold.” Bevan recognized that to conscript doctors to the largest socialist experiment in healthcare in the world he had to appeal not so much to their morals, but pockets.

There is much piety about the NHS. It is the envy of the world, though oddly Saudi oil barons still favor Cleveland Clinic and Texas Heart Institute over quaint little hospitals in rural Scotland. The NHS featured in Britain’s 2012 Olympic parade along with Mr. Bean and the human right activist, Shami Chakrabarti – only one of them was there for parody. Brits aren’t ones to posture self-righteously, except when it is about the NHS, when the violins come out full mast, and we’re treated to a spectacular display of sanctimony and disingenuity. The NHS is a religion which keeps its prophets happy.

Bevan, an arch socialist, Labour to the bones, and founder of the NHS, was no social justice warrior. He recognized that berating doctors into doing the right thing wasn’t going to work. Nor was selling them a utopian paradise. Remember, this was post Second World War Britain, when socialism was in fashion, and sympathies towards communist Soviet Union was an intellectual fad. Selling the concept of the NHS should have been a cake walk, most of all to doctors. But Bevan was a pragmatist, not sentimentalist. He knew that he needed more than ethos, logos and pathos.

So, in a stroke of everlasting genius Bevan allowed doctors to see private patients in NHS hospitals, a small quirk with considerable consequences. In essence, Bevan legitimized a two-tier system, in which the rich could jump queues, and doctors could serve the rich and the poor, though the rich a little faster, and with more personal touch. The NHS is living embodiment of George Orwell’s famous quip: everybody is equal, but some are more equal than others.

If the NHS isn’t the envy of the world it should be the intrigue of the world. Its survival wasn’t probabilistic. There are two reasons why the NHS hasn’t imploded – foreign-trained doctors and private medicine. The contribution of the private sector to the longevity of the NHS isn’t immediately apparent. Both tiers support each other. The parallel private track allows doctors in Britain to earn more than their NHS salaries, with only a little extra effort. Private insurance in Britain compensates handsomely.

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