Category Archives: Economics

Empathy and Prevention – a reply to Paul Bloom


In the May 20, 2013 issue of the New Yorker Paul Bloom argues convincingly that policy should include more rational argument and less empathy. Empathy leads us to spend a million dollars to get a single little girl out of a well, and yet have to scrap over pennies for building a fence that keeps the girl out of the well in the first place. Empathy leads us to commit an outsized amount of research funds to a deadly disease that affects only a few people, while ignoring or underfunding research that would prevent diseases in the first place. Empathy leads us to worry about the effects of mitigation of global warming because of anecdotes about people who might be put out of business with greater regulatory efforts to reduce carbon emissions, while not being able to envision and prevent the effects on future generations (now a cliche).

Bloom is right about all of this. But he is wrong about his conclusion. He writes (his final paragraph):

Such are the paradoxes of empathy. The power of this faculty has something to do with its ability to bring our moral concern into a laser pointer of focussed attention. If a planet of billions is to survive, however, we’ll need to take into consideration the welfare of people not yet harmed—and, even more, of people not yet born. They have no names, faces, or stories to grip our conscience or stir our fellow-feeling. Their prospects call, rather, for deliberation and calculation. Our hearts will always go out to the baby in the well; it’s a measure of our humanity. But empathy will have to yield to reason if humanity is to have a future.

To state that “empathy will have to yield to reason” is to think only rationally. Yet policy is made because of both reason and anecdote, analysis and empathy. Empathy is a form of expression of moral accounts. And values are critical to policy decision-making. To claim that empathy has to yield to reason is to contradict how we think, deliberate, and act. Instead of his weak conclusion that is so contradictory, we need to take empathy into account during policy-making. How might we do this?

First, by finding our own anecdotes. We need to find human images and stories related to prevention issues that invoke empathic responses. We need to use “Mad Men” tactics to persuade policy-makers of the value of preventive actions not just with cost-benefit and cost-effectiveness analyses, but also with narrative and emotion-evoking explanations. In the policy world we generally have been bereft of such approaches. We even can be antagonistic to them; we believe that the facts and science will do our arguments for us. But as Bloom so poignantly shows us, facts don’t hold a candle to the little girl in the well.

Second, by acknowledging the need to include empathy in our studies – how do our reactions to information and circumstances influence our willingness to be influential with policy analysis and decision-making? After all, policy analysis is just that – taking data of various sorts and trying to figure out the impact of various actions to fix a problem. Two analysts can look at the same set of data and arrive at different conclusions and courses of action because values and empathic responses are so critical to the analytic method. Our greater or lesser sense of the effects and empathic responses to those effects may strongly color our conclusions and action recommendations.

So while Bloom analyzes the problem correctly, he concludes with the wrong action statement. Empathy doesn’t have to yield to reason, analysis has to take both empathy and reason (among many other things) into account on an equal footing. And more importantly how we sell our recommended courses of action needs to play on the empathic response he so wisely discusses in his article.

BTW, often the concepts of empathy and compassion are confused. Bloom defines empathy correctly in his article, but then sometimes uses it as if it were compassion, which incorporates a component of compulsion to action. If the reader is interested in a more definitive discussion of the “spectrum of beneficence” and how empathy plays in the clinical encounter model, take a look at my 2009 article, “Kindness, not Compassion, in Health Care,” Cambridge Quarterly of Healthcare Ethics, 18, 287–299 DOI: 10.1017/S0963180109090458.

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In this case Scott Gottlieb has it wrong


A couple of weeks ago Scott Gottlieb wrote an op-ed rant in the Wall Street Journal entitled, “Meet the ObamaCare Mandate Committee.” I usually enjoy Gottlieb’s op-eds, though often don’t agree with him. He is usually thoughtful, even if he has a really negative view of the FDA, for example. I don’t share this view, but find his arguments thought-provoking. [I’ve told Peggy Hamburg in the past that I think the FDA does good work given its mandate and available resources. This is from many years and a number of companies in my venture capital portfolio that have had to get FDA clearance for devices or drugs. The FDA has an important population medicine role and it fulfills it very well.]

In Gottlieb’s current case, though, I can’t say I can even appreciate his viewpoint. It isn’t thought-provoking as much as significantly misleading and even poorly argued. Gottlieb, who seems to think that any cost considerations in medical decision-making is the equivalent of the Devil doing her dirty work, argues that the US Preventive Services Task Force (USPSTF) has been given too much power within the context of the Accountable Care Act, AKA ObamaCare.

The USPSTF has been in business since the mid-1980s. It was the first significant federal body to use carefully reasoned data analysis and literature searches to make recommendations related to screening for disease, or risk factor reduction. After thorough analysis of existing data about a screening test, preventive medication, or prevention counseling technique, the
USPSTF issues a letter grade on any particular item as follows:

Grade A The USPSTF recommends the service. There is high certainty that the net benefit is substantial.
Grade B The USPSTF recommends the service. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.
Grade C Note: The following statement is undergoing revision.
Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.
Grade D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
I Statement The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits & harms of the service.

The USPSTF uses very high criteria for determining these letter grades. ObamaCare determined (in my view appropriately – I’ll elaborate in a moment) that a recommendation of “A” or “B” would automatically qualify for full coverage in the federal mandate for benefits coverage. Thus Gottlieb is correct when he states that this committee “is empowered to evaluate preventive health services and decide which will be covered by health-insurance plans.” But he implies that this committee exists solely to do such a thing, and that its forward-going tour de force will be to wield power to force costs on the health care system by covering what it likes, and also reduce costs by downgrading items it doesn’t like.

[I say in my view appropriately because when I was Medical Director at Aetna in 1988 I helped develop a prevention rider that was based on the USPSTF’s recommendations – it was the only unbiased, evidence-based screening and prevention group in the nation at the time. Subsequently the American College of Preventive Medicine’s board of regents recommended that the Clinton Health Care Reform plan include the USPSTF’s recommendations also. I chaired the policy committee of the ACPM at that time.]

Back to Gottlieb. He also slams the USPSTF because of its change in screening recommendation for mammography in 2009. Many advocacy groups didn’t like the change because it reduced the frequency and starting age of screening for breast cancer (see chapter 5 of Prevention vs. Treatment by Dianna Petitti, vice-Chair of the USPSTF at the time). So, Gottlieb doesn’t like (a) the power the USPSTF possesses, (b) the fact that its recommendations may increase some costs, (c) the fact that some of its recommendations may decrease some costs if recommendations are not A or B, and (d) the fact that advocacy groups may have less clout than they have in the past.

You can’t have it both ways, Scott. Do you want evidence-based medicine? Do you want effective medicine? Or do you want only unbridled freedom for anyone to do anything they want, causing the out-of-control spiral of health care costs already burdening the system?

Let’s look at each of the complaints Gottlieb poses:

1. The USPSTF has some power. Yes, it does. Why is this a problem? He doesn’t say. He tries to argue that it is because it has made decisions in the past that he doesn’t like. But no one can argue that the USPSTF has been arbitrary and capricious in its decisions. It has looked at the evidence, modeled the harms and benefits (where information is available), and dispassionately made recommendations. Is that wrong? Would we rather have politicians making coverage decisions that usually have been arbitrary and capricious, mostly because of the politicians’ personal experiences only, or pressures from advocacy groups that then get resources that are far disproportionate to the diseases for which they advocate? I don’t think so. One way to get that arbitrary and capricious decision out of the hands of those who are (as Kahnemann would say) fast thinkers without using their slow thinking is to put it into the hands of those who can think slowly and methodically.

We know that advocacy groups and individuals don’t necessarily care about the evidence, they care about their advocacy mission. The USPSTF is scrupulous about avoiding conflicts of interest (financial) and conflicts of commitment (advocacy). Most medical specialty societies and advocacy groups can’t avoid these conflicts by definition.

Gottlieb is further worried that “the task force will surely recommend against many services that patients now take for granted, while mandating full insurance coverage for things that they’d be just as happy paying for.” As medicine advances we learn that some things don’t work which we thought did, and some things do work which we may not have thought did. Why shouldn’t coverages be shifted appropriately once we have this new information? Are we stuck in using arsenicals for syphilis and not antibiotics because patients (and physicians) are now “taken for granted?”

2. A or B recommendations will increase costs. Yes, they might. As Louise Russell points out in chapter 3 of Prevention vs. Treatment: What’s the Right Balance? (Oxford University Press, 2011), not all prevention is cost-saving. Some is merely cost-effective. Until now the USPSTF has not considered costs in its evaluation and recommendations. It can start doing so given the mandate from the ACA. But will it? It’s not clear. However, Scott complains that it is allowed to. Wait a minute. He also complains that prevention might cost money. Wait a minute. He also complains that some prevention might be dropped because it isn’t cost-effective. Wait a minute. I’m confused. Do costs matter or not? Does effectiveness matter or not? Gottlieb needs to tell us – is he for or against effectiveness as a criterion for coverage? Is effectiveness more important in prevention than treatment, or less so (or equal)?

3. C, D, or I recommendations may decrease costs. See #2 above. Plus: insurers still have the option to cover them. But why would they consider covering a D or I recommendation? A D recommendation says that the screening method creates more harms than benefits. This is a good reason to avoid its use. If an individual wants to pay for it to expose himself/herself to the harms then one can ask why an insurer should get involved. Further, one could even ask why an insurer should be on the hook to cover the treatment that likely will be required for the harms once this poorly informed and evaluated decision is made by the patient and provided by his/her physician.

For an “I” recommendation there isn’t enough information to know if screening or treatment is of any value. In essence this makes it like an “experimental” decision, except it is not being done in a controlled clinical trial, but simply out of ignorance by patient and provider. By what right does a patient have to get this paid for by the commons?

That leaves “C” recommendations, for which the evidence is not solid and the patient and physician need to have a lengthy discussion of its value and risks. Leaving aside the problem that most physicians don’t have the time to provide full information and explanation/discussion of these issues with patients, (and indeed don’t – see the February American Journal of Preventive Medicine article about this), the C category is one for legitimate discussion and disagreement perhaps. In this case insurers can decide based on the marketplace whether coverage is appropriate or not. Here is where advocacy groups and conflicted treatment specialists can weigh in with some clout.

4. Per #1 above, advocacy groups may have less clout than in the past because they have less influence on the USPSTF. But they still can argue their cases in responding to proposed recommendations – the recommendations are provided as drafts for a defined time period for comment before issued. They also can still advocate for increased research funding for their causes. The research is (and should be) outside of insurance coverage. First prove something works. Then let it be covered. Otherwise we’d be covering a lot of nonsense simply because one party or another claims it works.

I do agree that the process should be transparent. I doubt if the Task Force members would feel significantly different. Except they should be able to go about their work initially undisturbed by advocacy groups. If the task force misses a key study, the advocacy group has the option of pointing it out to them when the draft recommendation is released for comment. The recommendations are released usually about the same time as the evidence base review is released, usually in a peer reviewed journal.

And to go to Gottlieb’s introductory and concluding paragraphs about contraception. The actual coverage decision for that was not made by the USPSTF, but by a different body. The Obama administration could have rejected that recommendation for political reasons, and is modifying it now (like with the allowance of over-the-counter sales to minors of emergency contraception). How can Gottlieb imply or fault the USPSTF for that decision?

Wealth and Conflicts of Interest


Carl Bialik’s column in the Wall Street Journal this past weekend (Nov. 12, 2011) discusses the “Income Ladder’s Sticky Steps.”  He tackles the difficult question of assessing mobility, showing how defining the strata may change the conclusions that can be reached, including issues such as (1) What age groups should be included? (2) How do you handle natural progress of careers; older employed folks usually make more than they did when they were younger because their careers progress? (3) Would we be better tracking longterm earnings, as there can be natural fluctuations from year-to-year?

These have important implications when trying to look at economic progress.  For example, the Occupy Wall Street folks claim they are the 99% who are below the chasm of the 1% highest earners.  Of course they are – the 99 out of 100 people will be in the 99% by definition.  Except for celebrity guests of the Occupiers (who likely are in the 1%), those with the time on their hands to protest will be in the 99%.

Bialik states, without making further comments, “And none of the income measures explicitly includes wealth, which is distributed more unequally than income.”  This is an important statement.  Bialik is not the only one who recognizes but does not deal with the issue of wealth.  In Conflicts of Interest in medicine and health care wealth is at least partially ignored.  How?

Most conflict of interest disclosure requirements for authors in journals or speakers in continuing medical education events include provisions to disclose relationships with companies or other interests.

The International Committee of Medical Journal Editors states:  “Conflict of interest exists when an author (or the author’s institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties).”

The American Council on Continuing Medical Education (ACCME) states:

2.1 The provider must be able to show that everyone who is in a position to control the content of an education activity has disclosed all relevant financial relationships with any commercial interest to the provider. The ACCME defines “‟relevant‟ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

In the ACCME’s case financial relationships are defined as “…those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit.”

How does this normally exhibit itself in CME speaking activities?  In my experience the moderator of a session will state “so-and-so discloses that (s)he owns stock in [Drug] Company” or “so-and-so discloses that she has been paid an honorarium by [Device] Company” and it is left at that.  As we know, disclosure doesn’t fix the conflict, it merely reveals it.   Loewenstein notes related to the physician-patient relationship,

Disclosure may give the adviser a “moral license” for strategic exaggeration in the adviser’s best interest. (“I told her I had a conflict—now, I can recommend the surgery.”) Having disclosed a conflict of interest, moreover, advisors may feel compelled to give advice in an extra-forceful fashion.

This may be similar for the speaker-audience relationship, “I [the speaker] have disclosed my conflict, now I needn’t worry about it, or I may feel free to discuss it even more than if it were hidden.”

However, the key question that needs disclosure is “What does this relationship mean to the speaker and how has it influenced his/her presentation of information?”  Simply knowing that someone has been paid an honorarium or owns stock in an enterprise doesn’t tell the audience if such ownership is meaningful.  More importantly, what does that represent in terms of one’s income or wealth?  If the speaker has net worth of $100 million, owning $10,000 of stock likely is relatively meaningless.  On the other hand, if the speaker’s net worth is only $200,000, that $10,000 of stock may be critical for how she wants to please either the commercial interest (to get more stock or honoraria) or the audience (to purchase more of the product offered by the commercial interest).

(As an aside, at a recent Harvard University Program in Ethics and Health conference conditional cash transfer payments to encourage health promoting activities in second world countries was discussed.  As I recall, levels of payments had to approach 20-30% of annual income to get behaviors to change substantially.  This, of course, differs from findings related to physician behavior, which is influenced by small pharmaceutical company gestures.)

So, while ignoring wealth as the denominator of disclosure is usually done, we should consider the issue as a much more important measure.  Further there likely is some interactive relationship between meaningful financial ownership (wealth) and income.  Income fluctuations may have little meaning if the amounts are small, or if one has equilibrium with a lifestyle that is fully supported by drawdowns on existing wealth (not requiring additional annual wealth through income or increases in, for example, stock value).

Because of the complexity of the interaction of wealth, income, and meaningful bias/influence the leading medically-related institutions are moving to requiring disclosure of any financial relationship between an author/speaker/influencer and a commercial interest.  This makes sense, in that research indicates that we often don’t let data get in the way of our biases, which can easily come from financial self-interest, and that even small conflicts can result in unconscious bias.   Until we have more reliable data on the relationship between wealth and income this is probably prudent, but also recognizably excessive.

How to find the right balance?  More easily done when more research is completed.

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