Moving Mountains - A Socratic Challenge to the Theory and Practice of Population Medicine, by Dr Michel Accad
(available from Amazon.com)
This small book is an accessible and readible account of the philosophical basis of public policy relating to medicine, which has dominated government health policy for the last 30 years at least. It arises from a branch of medicine called epidemiology, which studies the possible control of disease by statistical analysis of human behaviour and the frequency of the occurance of symptoms and disease in population groups and any population as a whole.
The writer, Dr Michel Accad is a medical doctor who regularly publishes peer-reviewed articles on the philosophical aspects of healthcare and medicine and a Catholic who is concerned especially about the de-personalization of healthcare in the US. In this book, by reference to real policies and their effects, and with analysis backed up by scientific research, he explains why, in his opinion, it has gone so wrong. He does so through the vehicle of a conversation in the style of a dialogue that one might read in Plato's works. It is an imagined conversation between the ancient Greek philosopher Socrates and Geoffrey Rose, an Englishman who died in 1993 and who was one of the intellectual founders of population health medicine.
I would urge all doctors and anyone involved in the formulation of public health policy to read this book and consider its implications.
The starting point for our consideration is the bell curve showing the links between particular behaviour and risk of a particular in the population. In the examples given, which one assumes are typical, they appear to indicate that a certain proportion of the population is always at risk. So far so good.
The public policy that is implemented as a result of this analysis is based on an assumption that if the overal pattern of the symptoms or behaviours of risk in the population can be controlled so that a smaller proportion of the population appear to be at risk, the rate occurance of the disease of individuals will go down too and therefore, the general health of the population will go up. So for example, blood pressure can lead to heart disease so, the argument runs, if you reduce the average blood pressure of the whole population, you reduce the rate of heart disease in the population as a whole because fewer people are at risk.
By adopting this assumption, government directs public health policy therefore to controlling, not the desease, but the shape of the bell curve - and so the signs of risk to the disease or the behaviours that is felt lead to this disease. (Public policy cannot ever control disease directly because diseases, microbes are not subject to legal penalty or taxes only human beings are.)
At first sight this seems reasonable, but in fact there are a number of problems with this method and the assumptions behind it.
Most important first: however strong the argument in advance of implementing such policy, in practice there is little evidence that it actually works in helping people. Where there have been improvements in, for example, heart disease rates, it is as easy to demonstrate that these would have occured anyway due to improvements in other treatments or better advice delivered from the doctor, with people freely choosing to adopt them rather than being influenced by government actions directly - legal or financial regulation - to behave in the desired fashion.
Second, there seem to be a number of flawed assumptions that arise from bad philosophy - a wrong understanding of society, of man and even of the scope of natural science that lead to unanticipated detrimental effects as a result of implementing such policies.
Contrary to the assumption of those who create public policy, society is not an entity that can necessarily be controlled by the laws of cause and effect of classical physics in the way that a physical process can. Attempts to do so always involve centrally planned policies that attempt to direct behaviour either through incentives (usally tax) or legal penalties and thereby direct behaviour by restricting the freedom of all individuals for the sake, supposedly, of the few within the population who might have been at risk before and will not be now. We can't test this properly, because we never precisely who was at risk before and who will be saved by this policy because the figures that apply to the whole population are derived from statistical sampling of a small part of that population, not by looking at every person in the population.
We are not looking at Fred or Mary and saying previously you were at risk and now you are not because we can measure how your health has improved. We are looking at a small sample of the population and looking at the statistics of that sample perhaps a thousand people and then applying the numbers to the whole population. This makes it a hypothesis that is very difficult to test even if it works and produces the desired bell curve because at best we can suggest that as a result some unkown people are at less risk. The difficulty with this is that we cannot then check for unforeseen secondary effects in the particular people who are apparently saved that might be worse than if the policy had never been implemented. We will come back to this.
In practice, though, we don't always get the desired bell curve that public policy seeks to create. society as a whole rarely behaves as the policy intends. People cannot be controlled in this way because even if they stop doing one thing, it is almost impossible to predict what they will do instead.
Furthermore, risk of disease is rarely connected to one condition only and so the alternative behaviours that are induced by our policy might lead some people into greater risk of ill health, perhaps arising from some other unconnected disease. The mechanisms are always more complex than the picture used to describe them. This is the effect that free market economists know well - unintended consequences.
It gets worse. The recieved wisdom of what is good and bad for people changes over time and public policy, even if perfectly effective in controlling behavious, will always be behind the times as it is very slow to implement policy and change behaviour. Many will be aware that the behaviours percieved as good change as times goes on - eating butter used to be a good thing , then it was bad thing and now it is good again; saccharine was good and now is bad etc.
Nevertheless, one might argue, the science will very likely get better in time and at some point perhaps public policy could catch up and reflect it. But here's the point: even if we understood perfectly what patterns of behaviour were best, and even if we understood how to control the pattern of behaviour and the symptom levels in population as a whole, as indicated by statistical sampling, - in other words even if the problems so far mentioned did not exist - this approach would still not help us to promote health. This is because we do not know directly how the pattern in the society as a whole relates to the effects and behaviours of any given individual in that society. So, while we might show how a public policy might affect the public, we have very little idea how it affects each person within the public.
Accad points to this and explains how, in contrast, the promotion of personal free choice made in conjunction with advice from doctors that takes into account personal needs is still the only way we know of actually achieving greater health.
This approach to medicine doesn't just lead to policy that tries to control the behaviour of doctors and patients. It affects too the organisation and funding structure of healthcare systems directly and, Accad argues, detrimentally. A healthcare system geared towards this end of personal freedom and the common good, in the way that Catholic social teaching describes it, would look very different from any of the systems for providing health that have existed in the US and Europe over the last 50 years.
The health insurance model (including Obamacare) in the US and the single payer systems of European countries each have this philosophical flaw built into them to detriment of both patients and doctors. So the benefits that arise from these systems are there despite the systems, not because of them. And however, much those in Europe might argue that their system is better than the America (or vice versa) each is worse than what a system could be if Catholic social teaching based upon a right anthropology were taken into account. The drawback is that the person paying is not directly involved in the provision of care ie doctor or patient, but rather is an insurance company or government department. This means that they direct policy according to trends in overall expenditure without reference to individuals and so the same problems occur. All those aspects of healthcare to which a price can be attributed are governed by this bell curve mentality. As a result the provision of healthcare becomes bureaucratic and politicised, pressures are put on doctors to change ethical practices, and even leads to the redefinition of terms such as health and disease to validate government policy to the detriment of patient and doctor.
This is not to say that we should expect no limitation on funds, clearly monetary considerations must come into play or else insurance company, or state would go bankrupt. Rather, it says that we should look for the most efficient form of distribution of a scarce commodity with alternative uses to which a price can be attached. That is the free market. Where freedom is greatest prices are cheapest and availability is greatest. Furthermore, because this encourages free choices by the main protagonists - health care providers and patients - it allows also for the greatest flourishing of those aspects to which a price cannot be attributed, for example personal care and attention and a genuinely fruitful personal relationships between those involved.
I hope very much that doctors and those who influence health policy will read this book and think about how things could be improved. You can order it online from movingmountainsthebook.com
Dr Michel Accad is a medical doctor with a practice in San Francisco who regularly publishes peer-reviewed articles on the philosophical aspects of healthcare and medicine. He has also has a strong interest in the philosophy of nature and philosophical anthropology and has published in The Thomist. He gives lectures around the country on these topics and on medical ethics, medical science and healthcare economics. He is a committed Catholic and faculty member of Pontifex University, for whom he is currently creating a course on the Philosophy of Nature and Philosophical Anthropology as part of the Masters in Sacred Arts program. You can contact him directly through his blog AlertandOriented.com