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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The Value of the Humanities

In an article today in the Wall Street Journal – “Humanities Fall from Favor”, journalists Levitz and Belkin note how colleges and universities are losing humanities majors. The percent of graduates who have majored in history, philosophy, English, etc. has dropped to 7% nationwide in 2010 from 14% in 1966. At Harvard the drop has been from 36% to 20%.

A great deal of the reason for this drop is attributed to the practical orientation to getting jobs post-graduation. One Harvard student says, “People say you should do what you love…I don’t want to be doing what I love and be homeless.”

Here’s a thought: make a living, then do what you love. Universities should consider gearing up for humanities majors for people who have their careers and now want to return to college to take all of those courses they later wish they had taken, and major in those areas they wish they had studied in their youth.

That’s what I did. I was in a hurry to become a doctor. From the age of 10 I wanted to be one. My parents were always supportive and encouraging. Whenever I talked about wanting to perhaps major in music (I played trumpet) or philosophy (which I discovered in high school) I was discouraged: “But how will that help you become a doctor?” I had a lot of extracurricular activities related to clinical and research medicine. I thought I knew what I wanted to do.

But once I got into residency in family medicine I quickly recognized that I really was more interested in health economics, politics, administration, and ethics. I liked project work more than piece-meal work, which clinical medicine mostly entails. The manner of work was as important in my job satisfaction as the intellectual and emotional content of the work. Hence I moved into population health management (then called public health and medical care administration). This let me combine my interests in business and health management with my content intellectual interest in medicine.

At some point, perhaps around the mid-90s, when I ended up as a successful venture capitalist and had essentially fully funded my retirement economic (modest) needs, I was able to turn toward one of those loves: medical and business ethics. I went back to school to enhance my philosophy background, receiving a unique MA in philosophy from Wesleyan University. I was older than nearly every one of my professors, had worldly experiences they couldn’t deny when I asked practical questions of the academic studies, and was able to help fellow students with many of their science-related and business questions in informal discussions. It was a fulfilling experience culminating in my appointment at Wesleyan as an adjunct visiting professor of biology and philosophy, teaching epidemiology and bioethics. I loved working with those students – bright, inquisitive, social justice-oriented. When I moved full-time to Santa Fe I didn’t realize how much I’d miss that teaching.

When I tell others about this I often receive the response, “Boy, I wish I could do that.” And my guess is more would go back to get that elusive education if the system were set up for those students. There is talk about educating the “mature” student. And some schools may have begun classes to do so.

Now the down sides: (1) When you learn a discipline at an early age your mind is more absorbent. There’s no doubt it took me longer to absorb my readings in philosophy at age 50 than age 18. I’d diligently read the assignments, and often even more than assigned, and then get to class and forget the topic, let alone the specifics of the reading. Once reminded by the professor of the topic it would come back to me quickly and I could redact the philosophical arguments or history pretty well.

(2) Having worked in the medical industrial complex for almost 40 years it is part of my DNA. I know the ins and outs, have a full intuitive feel for what will work and what won’t, and can call on those years of experience to analyze new situations. I don’t have that same confident feel in philosophy. I write papers and provide arguments and (what I think are) new ideas, but am never quite sure I am fully briefed on the literature, or my arguments may have holes that need filling in. Peer reviewers will often point out those holes – but not always. [The peer reviewer system is unreliable at best – it is as dependent on the biases and attention of the reviewers as it may be on their overall capabilities. More on this another time.]

(3) There may be a collegial civility of professors for more mature audiences that sugarcoats what would otherwise be more appropriate criticism. None of us wants to be criticized unfairly, but we can’t advance as well if we are not adequately criticized as we go along in our learning process.

Meanwhile, I’m blessed (and grateful to Wesleyan, the University of Toronto’s Joint Centre for Bioethics, and my venture capital success) to be able to have the luxury of concentrating on ethical issues in medicine at this time in my life. My most recent paper should be out in the next couple of months on the “hard questions” of causation and prevention, to be published in the Journal of Medicine and Philosophy.

Another review of Prevention vs. Treatment: What’s the Right Balance?

Bhaven Sampat has written a review of our text in Global Public Health 8(2):236-9, 2013. His summary judgment is:

Having expressed some minor complaints, I emphasise that I like the book and recommend it. I have long been interested in teaching a course on cost-effectiveness analysis that goes beyond technique and engages some of the political and ethical issues behind the scenes. This volume would be a good introduction to these themes in the context of prevention and treatment. The first three chapters would also provide a very good short introduction to the prevention versus treatment debates for policymakers and others interested in a general overview of these issues.

The first three chapters include the introduction (Faust and Menzel), economics (Altarum Institute – Miller, Roehrig, Hughes-Cromwick, and Turner), and cost-savings/effectiveness (Russell). We’re pleased he liked these chapters and they tend to be the most quoted of the chapters on policy-related blogs.

Let’s look at his “minor complaints.”

First, he doesn’t think the third section of the text, on how religious perspectives look at the balance, are valuable. “Though these chapters provide a useful introduction to medical ethics issues from different traditions, I do not think they connect well with the other chapters or speak to the balance question.” Given that other reviewers have praised the connectedness of the chapters, I’d like to better understand what he means by that portion of his comment. But more importantly, his “speak to the balance question” comment is puzzling. Each chapter in the third section specifically looks at how each religion represented considers how to balance prevention and treatment. The problem is that, except for Seventh Day Adventism (SDA), they all come out on the side of treatment without actually making the comparison in their religious texts or commentaries, except as gleaned from isolated statements.

This was surprising to Paul and me as well – none of Protestantism, Catholicism, or Judaism explicitly address the balance between treatment and prevention. This is the interesting finding from this section. When pushed, the authors of these chapters, who originally all stated there is no preference stated, eventually intuited that indeed treatment is commanded to take precedence in most instances (except in the “community elders” argument of Judaism). And even when Roy Branson’s chapter on SDA went a little deeper he found it easy to conclude that while prevention was still very important historically and theologically, there could be some concern that the SDA treatment system, which today is one of the largest in the US, is overwhelming in its use of resources, worrying that it could crowd out the prevention orientation.

Perhaps Sampat thought that they don’t address the balance question because indeed within the traditions they don’t explicitly address it, and he confused that with not asking or addressing the question within the chapters?

To the second minor complaint I plead guilty: I approached the book originally with the strong bias that prevention is underfunded and we don’t devote sufficient attention to it in policymaking or in the clinic. The latter is demonstrable with the under-use of prevention resources, even those considered cost-saving and cost-effective. This bias was stated explictly in the introduction, wherein Paul and I illustrate this underfunding and under-attention emphasis in various settings and the US’ clear bias toward treatment and away from prevention. This has been my stance throughout my career and I still believe it correct. And here is how I believe, from a policy perspective, this conclusion is dispositive: everyone talks about how treatment care costs too much – and by “health care” they usually mean “treatment” care. And everyone talks about how we don’t do enough in prevention. Yet we continue to pay for treatment care (almost at any cost) even when we know that additional dollars to prevention could help (but not cure) under-utilization of prevention. I address this in chapter 6 of our text, where I point out that funding alone (e.g. first dollar funding of prevention by the Affordable Care Act) won’t fix the access and other issues associated with successful prevention for individuals and communities.

Having said this, Sampat would be surprised to find how much my own view and public stances on prevention have changed since beginning the book. Now instead of speaking in full defense of prevention I add nuances of concern and reality. I even have one talk, “The Moral Problem of Prevention,” where I explicitly point out these concerns and why prevention might not take the theoretical moral high road which it used to take.

I agree also with Sampat’s concern that we didn’t spend more time on both the politics of prevention (mostly just covered in Diana Petitti’s chapter) and how the values-attitudes mix impacts both policy and individual decision-making. I call for more imagination in effecting the “affect heuristic” in prevention – we need to figure out how we can evoke better future suffering because of a lack of prevention in order to have decision-makers understand better their effects when they don’t fund prevention. Indeed the theme of the American College of Preventive Medicine’s 2015 meeting will be just that – Imagination in Preventive Medicine, from a policy and delivery perspective.

Generally those who practice prevention both in the public health and private clinical spheres have not been very good at marketing health to their stakeholders. Certainly marketing techniques like those used for unhealthy products and services have evolved into fine arts – glossy well-designed corporate annual reports, while many public health programs still use the equivalent of xeroxed, hand-folded brochures. We need to find efficient, effective ways to deliver better messages, motivate people in different directions, and change tastes (literally).

Perhaps Paul Menzel and I will produce volume 2, which would address some of Sampat’s minor complaints. Maybe he’d like to explore the political context more? We would have liked to have addressed some of his complaints in our first volume, but frankly were concerned about going over 400 pages for practical publication purposes.

At the same time, we thank him for his comments and review.

Can you remember…

…everything you did 15 years ago? I’ve gone to meals with younger colleagues with whom I haven’t had a prior acquaintanceship and two years later forgotten we had had lunch, and even who they were, mostly because we didn’t have a significant ongoing relationship at a time when so much was going on in my life.

Just yesterday I was in touch with a friend who is a family physician in Florida. I had coincidentally met a woman who was moving to my friend’s town and she was looking for a family physician. I recommended my friend and gave her his work phone number. When I was writing to my friend two weeks later I remembered the referral, but couldn’t remember the circumstances under which I had met the woman, nor could I remember her name. This wasn’t a matter of my bad memory, as much as the constant and intensive bombardment we have of data, much of which ends up being contextually forgotten because of its relatively trivial nature (trivial related to the daily meaning of our personal lives).

In this context, I can understand if Herman Cain doesn’t remember a woman with whom he had a meal and then allegedly made unwanted advances toward so many years ago. I’m not justifying or condoning his actions if he indeed did inappropriately touch her; that would be reprehensible. But if he forgot who she was, I could understand. I met with many entrepreneurs in the 1990s during my early venture capital days. Had meals or coffee with them. But I didn’t invest in their companies and don’t remember them now.

While I’m not justifying his actions, I also wouldn’t suggest that if he is “not remembering” because he is lying to avoid responsibility that would be inappropriate also, and further not justifiable.

The questions are, “How far back and how significant does one’s contact with someone have to be to be held accountable now for those distant actions? What is a reasonable balance – time, distance, maturity – to which we should be held blameworthy (or praiseworthy)?”

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.