This excellent NY Times Magazine article by Katy Butler describes the awful price paid by the Butler family when her father was given a pacemaker that kept him alive too long. The hospital, surgeon, and pacemaker manufacturer benefited by thousands of dollars. Her father was too out-of-it to make decisions about his health. His wife, who made the decision, was given too little information (not told of a much better alternative, not warned of the eventual outcome, which was likely) and, Butler seems to say, decided too fast. The pacemaker was implanted so that he could have a hernia operation — the hernia surgeon wouldn’t operate without it.
Butler’s article is excellent because it is personal, moving, and sheds light on a big issue that I rarely read about: the way “informed consent,” in practice, favors overtreatment. The patient or their representative makes the final decision, yes, but in most cases their decision is based mainly on information they’ve been given by their doctor or hospital, who benefit from one decision (yes, do something) but not the other (no).
The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them — specialists, hospitals, drug companies and the medical-device manufacturers — spend money lobbying Congress and the public to keep it that way. . . The profit margins that manufacturers earn on cardiac devices is close to 30 percent. Cardiac procedures and diagnostics generate about 20 percent of hospital revenues and 30 percent of profits.
I liked Butler’s article partly because I’d had a similar, much smaller experience. I’m still pissed that during a discussion with Dr. Eileen Consorti, a Berkeley surgeon, of the costs and benefits of surgery to fix a nearly-undetectable hernia, she said nothing about side effects other than death. There are other possible bad effects of general anesthesia, which the operation would have involved. I complained to her assistant about her incomplete description of the risks. She didn’t respond, other than to threaten legal action (for not removing criticism of her for something else, I suppose).
Of course doctors, hospitals, and so on benefit from treatment. For me, the problem arises when (a) the benefits to patients are slight (compared to the benefits to the doctor, etc.), zero, or unknown or (b) the costs to patients are not well described. In both of these cases — the Butler family’s and mine — both (a) and (b) were true. Condition (a) is overtreatment, but Condition (b) makes things worse. If you propose to do something to me that could have an awful outcome, and from which you benefit, I would like to be warned of the awful outcome.
Dept. of Amplification. My original mention of Consorti was about how I couldn’t find any studies supporting her recommendation of surgery. She had said such studies existed. When I couldn’t find them, she promised to find them for me, but, several years later, has yet to. In the meantime, a reader of this blog found a relevant study (thanks, Kirk). Its results support my decision not to have the surgery that Consorti recommended.
Robin Hanson on doctors. How could we be this wrong about medicine? Thanks to Peter Spero.