This is the raw dialogue between myself and BillyJoe7 on Dr. Novella’s excellent Neurologica blog. I thought it was worth posting because I would like to expand a bit on the thought process behind it. I apologize for the horrible formatting (blame Mycrowsoft). It starts out with Dr. Novella talking about the standard of medical care, and ends with me shamelessly hijacking the topic.
raylider – that’s why I added “because of the tremors.” They are not a good reason to evacuate. That would mean it’s reasonable to evacuate every city after every tremor (or at least ones in earthquake areas).
If a patient asks me, “should I get an MRI scan,” and the official evidence-based recommendation is no, I tell them no, not “it’s up to you.” They may have a tumor – anyone might – and that absolutely opens me up to lawsuits. But I’m relatively safe if I am following the science and the standard of care.
# raylideron 25 Oct 2012 at 1:06 am
Thanks for the reply, but I have a further inquiry regarding the ethics of the following:
“If a patient asks me, “should I get an MRI scan,” and the official evidence-based recommendation is no, I tell them no, not “it’s up to you.” They may have a tumor – anyone might – and that absolutely opens me up to lawsuits. But I’m relatively safe if I am following the science and the standard of care.”
— Shouldn’t it be up to the patient? Yeah, the headache is 99% likely to not be a tumor. But if your prescription is to always not get an MRI, you will have a 100% chance of being wrong at least in the instance of the 1% chance that it is the tumor. I would guess the reason that you don’t say “it’s up to you” is because it’s not the patient’s money/resources to be commanding because insurance/government are paying. Given that the patient comes in with cash and their own money, shouldn’t it be up to the patient to decide whether he wants to investigate unlikely scenarios? Is it likely that it’s a tumor? No, it’s highly unlikely. Do you know for sure: no. Caveat: there are instances where unwarranted diagnostic tests are harmful by increasing the likelihood of a false positive, as in the case of a low prevalence disease and a test that isn’t specific enough, but let’s assume that was not a factor for the purposes of this argument.
# raylideron 25 Oct 2012 at 1:08 am
P.S. Can you clarify what opens you up to lawsuits? Saying “no” or saying “it’s up to you”?
BillyJoe7on 25 Oct 2012 at 6:12 am
“Shouldn’t it be up to the patient?”
No, it should not. Resources are limited. If everyone with a headache wanted, and got, an MRI, patients who have real indications for an MRI will be pushed to the end of a very long queue. They are the ones who are more likely to have a brain tumour and they will have a delayed diagnosis.
“Yeah, the headache is 99% likely to not be a tumor.”
“But if your prescription is to always not get an MRI, you will have a 100% chance of being wrong at least in the instance of the 1% chance that it is the tumor.”
Clearly, Steven Novella is not going to miss 100% of brain tumours that cross his desk.
Obviously, if the headaches are accompanied by other suggestive symptoms, or if there are abnormal neurological signs, that would probably constitute a science-based ndication to do an MRI.
“Given that the patient comes in with cash and their own money, shouldn’t it be up to the patient to decide whether he wants to investigate unlikely scenarios?”
They would still be using up scarce resources (manpower, MRI machines), and some poor individual is going to miss out on his science-based indications for the scan or have a delayed diagnosis. If you think that is ethical, you have a different ethical sense than most doctors (I hope).
“there are instances where unwarranted diagnostic tests are harmful by increasing the likelihood of a false positive, as in the case of a low prevalence disease and a test that isn’t specific enough, but let’s assume that was not a factor for the purposes of this argument.”
Raylider and BillyJoe,
If public resources are to be spent on an unlikely tumor expedition against the current standard of care, then it is clearly unethical.
However, if the patient is sufficiently informed of the risks and benefits, false positives and negatives, and is still willing to devote his resources to get the optional MRI, unless a public hospital will bump a patient in need for an optional scan, I see no ethical problem with this.
For example, in many parts of Asia, private MRIs are quite affordable and not uncommon. It is often less than a co-pay in the US (USD$200-$400 all inclusive, http://www.cth.org.tw/02department/depa02_5center8.html). Disclaimer: just an example, I am not associated in any way with this organization.
On a tangent, I believe that a greater ethical problem arises when the cost of health care is artificially inflated due to an inefficient insurance system, and rendered inaccessible to millions as a result. When a health care provider will gladly accept self-pay for 1/10 of the price they bill the insurance company, something is seriously wrong.
# raylideron 25 Oct 2012 at 12:23 pm
“They would still be using up scarce resources (manpower, MRI machines), and some poor individual is going to miss out on his science-based indications for the scan or have a delayed diagnosis. If you think that is ethical, you have a different ethical sense than most doctors (I hope).”
MRI’s are scarce? Why are they scarce? I don’t think a person who brings their own money is using anyone’s resources other than his own. It’s not as though a unit of MRI disappears because he used it. The patient traded his money, which can then be used to create more MRIs. It’s not as though when you buy an iPhone, there are less iPhones to go around. No, Apple uses the money to make more iPhones that are cheaper and better. So I’m not sure why that doesn’t apply to MRIs.
May be I’m focusing too much on the hypothetical here, since we have a government controlled healthcare system and few people actually pay for their services. But given the exception when it is the patient’s personal resources at stake, it is absolutely ethical for him to trade his resources for other’s products. No one else is anymore entitled to someone else’s property.
I’d say it would be unethical for the doctor to be the one that decides how to ration resources and place prices on other people’s lives. Yeah that’s great that the chance is 99.999 in the patient’s favor, but tell that to the family of the patient who went home with a tumor. The fact of the matter is, when the patient presents, the probability of him having a tumor is actually either 0% or 100%. And the 99.999 is the epidemiological figure derived from past populations, it does not apply to the individual. Also, it may be that in the case of the headache, the likelihood of a tumor is low, but the general cut off for most can’t-miss-Dx’s is what? 98%? You’re at 98% confidence that the patient didn’t have an MI, or PE, or whatever else? So you’re going to miss 2% out of every hundred and send them home? This happens all the time. Now, in the current system there is no other way, but I don’t see a problem with a person deciding how to care for themselves and using their own resources.
# raylideron 25 Oct 2012 at 12:31 pm
In fact, as you say “if every patient came in and got an MRI.” How AWESOME would that be? You would have tons of patients, paying out of pocket for MRI scans. The industry would boom, and the economy of scale would reduce the prices of MRI’s for everyone, while increasing quality.
# BillyJoe7on 25 Oct 2012 at 4:48 pm
Raylider & skeplanker,
You are talking about a different category or resources than I am.
I’m not talking about personal financial resources, I’m talking about the world’s resources in time, money, and manpower.
Not everyone can become a radiographer or radiologist. Of those who can, not all would want to be one. So there’s a limit already. Also governments, quite rightly, regulate to some extent how many go into the various professions. And there are market forces, but they don’t work as you suggest. If there is a siphoning off of a large section of they population into the lucrative fields of radiography, radiology, and MRI machine manufacturing (because everyone with a headache wants an MRI), there will not be enough farmers to feed us, carpenters to build our houses, and teachers to teach us how to do all these things.
So there’s no choice. Radiographers, radiologists, and MRI machines are going to be rationed, whether we like it or not. The question is how do we ration them. The obvious answer, at least for readers of this blog, is based in science, not personal financial resources. It is also the ethical solution.
We are talking about the same resource, specifically the alleged scarcity of MRIs and radiologists. From my previous post, “For example, in many parts of Asia, private MRIs are quite affordable and not uncommon.”, the market forces have already brought the pricing down to an affordable level in those regions, where there had been, but no longer is, a rush of capital flowing into MRI imaging equipment investment, specifically self-pay private comprehensive health check-up clinics in Asia. The cost of a self-pay comprehensive 2-day health check was cut more than half to a bit over 1k as the number of clinics flourished. The public health system and resources were not impacted significantly as the clinics are private, for-profit organizations or branches. THAT is how the market really works. There have been no reports of people on public health care systems being denied MRI scans because the hardware and personnel were snatched up by private clinics.
“A siphoning off of a large section of the population” is a strawman argument. A large section of the population woud also love to be the CEO of Mycrowsoft and make obscene amount of money. I’m sure most of them didn’t become CEO so they could be farmers and feed everybody to avoid extinction of the human race.
# BillyJoe7on 26 Oct 2012 at 6:22 am
” The cost of a self-pay comprehensive 2-day health check was cut more than half to a bit over 1k as the number of clinics flourished. ”
A useless health check is still a useless health check when it is half-priced.
Medical practitioners should be deciding what investigations should be performed. If there are clear evidence-based indications to do an investigation, it should be done unless the patient refuses. If there are clearly no evidence-based indications to do an investigation, then it should not be done and the patient should have no say in the matter. In the grey area between these two clear cut cases, then and only then should the patient have an input to the decision to do the procedure.
“A useless health check is still a useless health check when it is half-priced.”
Your assumption is that a comprehensive health check is useless. Assuming it is a long shot (which arguably it is not), as long as the patient is properly informed, sometimes a hunt down a rabbit hole yields a rabbit.
For example, a lottery ticket is a tax on those unfamiliar with the concept of expected value, and is one of the worst government-sponsored investments one can make. However, one should be free to squander funds on lottery tickets, despite what the mathematician recommends. Informed or not, it is the concept of free will. And in my opinion, this is exactly how CAM thrives minus the payout.
“In the grey area between these two clear cut cases, then and only then should the patient have an input to the decision to do the procedure”
I disagree with this viewpoint. In an extreme case, if Bill Gates wanted to buy an MRI machine and do MRI’s on himself, his dog, and dead fish, for any reason (health investigation, reclaim the Ig Nobel prize, etc.), nobody should have a say in how he spends his money, since an MRI machine is a commodity and not in short supply.
Another distasteful example: People are free to purchase as many wasteful SUVs as they wish, and drive around in circles just for fun, even though this arguably wastes a limited resource (oil) and affects other (emissions).
Unless one’s decision is clearly and directly affecting other’s well-being by depriving limited resources (e.g., monopolizing a resource), in my opinion one should have full agency of his own body, including how to utilize his available resources, and how and when to end his own life. It’s called freedom, and last time I checked, it was in the Constitution of the United States.
# BillyJoe7on 26 Oct 2012 at 2:31 pm
It is not my assumption. Routine health checks are not evidence based activities. In fact, the evidence is that they are not beneficial and do not save lives. On the contrary, they tend to lead to further useless chases down rabbit holes. The fact that occasionally a treatable problem is picked up is not a justification for their use.
I don’t buy lottery tickets for that very reason, but if you want to buy one on a whim, go right ahead. But please do not waste limited medical resources on a whim. Medicine is not a commodity to be bought and sold on a whim, it is a scientific activity. Or it should be. Or don’t you support the purpose of this blog which is to promote science-based medicine.
“Routine health checks are not evidence based activities. In fact, the evidence is that they are not beneficial and do not save lives.”
I would be interested in seeing this evidence. The following is the opinion of the NIH:
“Regular health exams and tests can help find problems before they start. They also can help find problems early, when your chances for treatment and cure are better.”
“Medicine is not a commodity to be bought and sold on a whim”
I should stop buying aspirin then. Medicine, medical equipment, and medical services are commodities. You can buy it with money, and not have to rely on an authority to determine what is best for you or what level of care you must receive.
“Or don’t you support the purpose of this blog which is to promote science-based medicine”
I support SBM fully. But above all I believe in freedom.
I believe that better education in critical thinking to be the long-term solution, which I feel is better than the Darwin way.
This discussion is WAY off topic and I apologize to Steve for that.
BillyJoe, if you want to continue discussion about health freedom, I suggest we do it here: http://notsofoulmouthedrant.blog.com/2012/10/18/health-freedom/
# BillyJoe7on 27 Oct 2012 at 1:01 am
The opinion of the NIH is not evidence.
I’m not going to provide you with the evidence but, if you want to find the evidence for yourself, I will give you this reference as a starter:
And how is buying aspirin a whim?
There is science-based evidence of benefit. Unlike an MRI for a headache.
But health freedom?
This is for health fraudsters to rip off the public without government interference.
At least I know where you are coming from now.
From the first line of the link you posted:
“Please note: the following refers to routine physicals and screening tests in healthy, asymptomatic adults. It does not apply to people who have been diagnosed with diseases, who have any kind of symptoms or signs, or who are at particularly high risk of certain specific diseases.”
I agree with that disclaimer. However a blanket statement saying a health check is useless, or that further investigation of a symptom is useless, I cannot agree with. An MRI for a headache, depending on the nature of the headache, in my view can be possibly construed as “further investigation”. I reviewed Steve’s original post and it actually did not mention headaches specifically, so it was presumptuous of us I guess.
I mentioned aspirin as an example to illustrate the fact that medicine is in fact a commodity, and in most cases if one chooses to procure more than is reasonably recommended, it can be wasteful but does not materially affect others, and one should be free to do so, however ill-advised.
And the last point on fraudsters ripping off the public under the guise of health freedom, I would completely agree with that. My position is that even though I do not like, much less advocate, people being ripped off, people should have the choice to *voluntarily* be ripped off with informed consent. There is a subtle difference.
# BillyJoe7on 27 Oct 2012 at 3:56 pm
It seems your area merely confused by the terminology.
A “health check” in medical parlance is a “routine physical”, and any test done as part of a “health check” is a “routine test”. Doing an MRI for a headache falls into that category. There must be additional symptoms or signs that lead to an evidence based decision to do an MRI.
“people should have the choice to *voluntarily* be ripped off with informed consent. There is a subtle difference.”
I think you’re confusing subtlety with confusion. (;
I must remember that sentence:
people should have the choice to voluntarily be ripped off with informed consent.
I agree that there was imprecision when I used the term “health checkup”. It is not a “routine physical” but a “comprehensive screening test”, as “routine physicals” do not generally include the advanced screenng tests performed. I originally brought up the cost of this optional screening package to point out the fact that MRIs are neither scarce nor uncommon, and without explicitly saying so, implying that one could get an MRI scan even if insurance did not cover the expense. I argue that all this is irrelevant for the key issue that we differ on, which is whether a patient has the right to spend his own money on a medical procedure (specifically, an MRI test). You state:
“If there are clearly no evidence-based indications to do an investigation, then it should not be done and the patient should have no say in the matter”
My stance is that a patient should be free to do whatever he wants to himself, subject to limitations stated previously. In other words, if it on his own dollar, the patient should absolutely have a say in what treatments he gets or refuses, whether it is SBM or quackery.
If a company is subsidizing the gasoline in an employee’s personal vehicle, which is recommended to run on regular, it would be unreasonable to ask the company to pay for premium. However the employee is free to believe in whatever woo he wants and fill up on premium, add in octane boosters, miracle fuel pills, and whatever useless additives money can buy, possibly causing damage to his own car, if it is on his own dollar. The same concept applies.
That is “the right to be ripped off”. The difference is although neither of us think people should be ripped off, you think that people do not have the right to be ripped off, and I do. That is the subtle difference I am talking about, which hopefully is less confusing.
# BillyJoe7on 29 Oct 2012 at 6:46 am
If you support the science-based medicine promoted by this blog, then “health freedom” is out the window. Only medical experts can decide what is science-based medicine because only medical experts have the background knowledge, and the specific knowledge, and the working knowledge to make those decisions. To go with the decisions of non experts like patients against the advice of medical experts means giving up on science-based medicine.
An additional reason why patients should not be allowed to use limited resources against science-based medical advice just because they can afford to do so, is because others with well-defined indications for testing for diseases that can be cured if diagnosed early, will end up with delayed diagnoses and worse prognoses.
” you think that people do not have the right to be ripped off, and I do”
Yes, I’m no libertarian. People should be protected against fraudsters. Everyone, you and me included, is or has been at some stage of their life, vulnerable to being defrauded. I see no logic in assisting fraudsters by refusing to protect their potential victims.
I understand your viewpoint and although I respectfully disagree, I rest my case.
# BillyJoe7on 29 Oct 2012 at 2:02 pm
I think I understand your viewpoint as well, but I find it hard to respect it.
Everyone for themselves is not even the law of the jungle.
The law of the jungle includes reciprocal altruism and kin selection.
I think we can do better than that.
I got too busy to continue on with the dialogue and I ended it. However I do have some time now and will expand on it a bit here:
BillyJoe7: “If you support the science-based medicine promoted by this blog, then “health freedom” is out the window. Only medical experts can decide what is science-based medicine because only medical experts have the background knowledge, and the specific knowledge, and the working knowledge to make those decisions. ”
SBM and health freedom are not mutually exclusive; that is a false dichotomy. In a perfect world, medical practitioners are able to provide the best advice. In the real world, medical practitioners are human, and can be spectacularly bad at assessment.
BillyJoe7: “To go with the decisions of non experts like patients against the advice of medical experts means giving up on science-based medicine.”
First there is the faulty implied premise that getting an MRI scan (which is exploratory in nature) when evidence does not warrant it, is a decision that is *mutually exclusive* with SBM. If it does not alter the course of treatment, it is simply wasteful and not mutually exclusive. The conclusion does not follow in the MRI situation. If a patient were to decide against taking life-saving drugs and favors prayer or magic, that is altering the course of treatment, and I concur that is giving up on SBM.
BillyJoe7: “Everyone, you and me included, is or has been at some stage of their life, vulnerable to being defrauded. I see no logic in assisting fraudsters by refusing to protect their potential victims.”
From a purely moral standpoint I agree with this statement. I would also like to note that protecting people from their own stupidity is a noble gesture that is seldom well-received. However, I am not against all forms of protection against fraudsters. I am against an “absolute” protection in the form of an authoritative mandate, science-based or not. In relevant terms per discussion above:
BillyJoe7 thinks that the patient does not have the choice to get an MRI, self pay or not, if the current guideline says it is unnecessary.
I think that once properly informed of the risks and benefits, the patient should be able to choose to undergo an MRI, if is willing to use his own resources and not materially affect others by doing so.
The right to get an MRI should not be confused with the need to get an MRI. For example, one should be able to get an MRI scan out of simple intellectual curiosity. To mandate that one *must not* get one unless medically necessary even if using private resources, is not compatible with reality nor is it conducive to intellectual freedom.
Disclaimer: the context is different in that BillyJoe7 likely referred to the MRI for a headache, which is for diagnosis purposes. My main point is that it should not be an authoritative mandate, for reasons beyond medical necessity.
BillyJoe7: “An additional reason why patients should not be allowed to use limited resources against science-based medical advice just because they can afford to do so, is because others with well-defined indications for testing for diseases that can be cured if diagnosed early, will end up with delayed diagnoses and worse prognoses.”
I agree if the premise of MRI resources were limited to the point where by getting an unnecessary MRI would deny someone in the immediate population that truly needed one. That has been shown to be false. People that would not be affected either way (remote villages) do not factor into the equation.
BillyJoe7: “I think I understand your viewpoint as well, but I find it hard to respect it. Everyone for themselves is not even the law of the jungle. The law of the jungle includes reciprocal altruism and kin selection. I think we can do better than that.”
Strawman argument. I never advocated an “Everyone for Themselves” viewpoint. I am not against some forms of regulation aimed at reducing quackery. I am against absolute mandates that say “you must not do this because it is not compatible with our current understanding”. I am ok with a regulation saying “this practice is not compatible with our current understanding, here are the risks of this unproven method, and if you choose to practice this on yourself, do it on your own dime”.
I fail to see the immediate relevance of “reciprocal altruism” and “kin selection” in this context. In a Darwinian sense, those that choose to undergo ineffectual treatments will likely be not as successful in surviving and reproducing. An authoritative ban may be a well-intentioned altruistic measure, but there is little reciprocation, and the social cost is difficult to measure.
I have two more analogies (I like analogies).
Tobacco, drugs, and alcohol. Smoking is known to be hazardous, drugs have little social benefit, and excessive drinking is not conducive to well-being. Banning tobacco and drugs, and banning binge drinking would be a science-based approach. Yet that is not a socially acceptable option. Most people would accept a warning label and education campaign. Most would also accept regulation that limits its effects on others, such as second-hand smoke and public drunkenness, and driving under the influence.
Religion. There is plenty of bigotry, intolerance, and hate in many of the prevalent monotheistic religions. Yet it is stated in the Constitution of the United States, that people are free to worship any imaginary friend or friends of their choosing, as long as the practice is private and does not affect others. Hence the separation of church and state, mosque and state, temple and state, FSM and state.
Freedom is not imposing one’s belief on others. I stated “the right to be ripped off” just to make the point that I am willing to defend freedom, even if I do not agree with some of the consequences.
One thing I like about science blogs is that at least the conversations are more intelligent and the viewpoints more thought out. Those who cannot formulate a coherent argument usually pick easier places to post their nonsense.
Any comments are welcome.