This is Chapter 10 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.
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Chapter 10 – A Tyranny of Experts

I must preface this chapter with a confession. For nearly 12 years now I have made my living, for the most part, as an expert. During this interval various organizations have paid me for my expertise on cardiology, on electrophysiology, on the healthcare system, on product development, on quality systems, and probably on some other things I can’t remember right now. So what I am about to say, I say with some reluctance, and (considering that my current or potential future clients might read it) with a bit of trepidation.

Further, I must confess that some people who knew me during the 20+ preceding years, in which I made my living as a practicing cardiac electrophysiologist, have expressed their astonishment that anyone thinks I am an expert on anything other than pure electrophysiology. To these, I have patiently explained that I have always considered myself primarily an historian and an observer of human behavior, who picked up some electrophysiolgy along the way in order to pay the bills, similar to the way that (by analogy only) Jesus picked up carpentry, St. Paul tent-making, Albert Einstein patent-office-clerking, and Ted Bundy legal-aiding.

If this display of hubris does not shut them up, I go on to explain my definition of an expert: an expert is any person to whom any other person is willing to pay cash dollars for their thoughts and opinion on any topic. It is not my fault that some people are willing to reimburse me for my thoughts on stuff outside the field of electrophysiolgy. And so, fair and just or not, I am an expert.

Having made this disclosure, it pains me to note that, in general, experts have become a problem.

Experts are a natural spin-off, an unintended consequence if you will, of the Age of Reason, an era which Western Civilization has enjoyed now for about 500 years. During that time, the concentrated application of reason to the human experience has brought us many good things, including Newtonian physics, classical liberalism, public education, renal dialysis, air travel and iPhones, among several others. Along the way, human knowledge has exploded into so many different areas that nobody can possibly learn it all. And hence we have developed an essential need for experts – people who have learned a whole lot about some circumscribed region of human knowledge.

Indeed, experts have become so indispensable that over the last century or two they have risen to the top of the food chain. Generalists – people who have broad knowledge but no specific, recognized areas of expertise – have become greatly devalued in Western society. Polymaths are passe. And so, an unintended consequence of the Age of Reason is that the experts have risen to power.

Anyone who has read this far in this book will know that your humble author (being a classical liberal) believes that most big decisions affecting individuals ought to be made by the individuals themselves. To the extent that certain big decisions must be made on a collective basis (and some decisions do need to be made this way, which is why we need governments in the first place), I believe those decisions ought to be directed by people who have a broad depth of experience, and who have broad knowledge, and who take a broad view. I am partial, for instance, to Jefferson’s notion of citizen-legislators.

When Jefferson lived, about half-way through the Age of Reason, it was still possible to imagine such a thing. But he lived before experts actually ran everything.

The Problem With Experts

There are inherent problems with experts running the show.

Experts, by definition, have a circumscribed and insular view of things. They know a lot about one area of endeavor, which is fine – but they take great pains to know “nothing” about any other areas. If they attempted to display a broader knowledge, they would be encroaching on the turf of some other expert, and therefore, they would be threatening the very notion of an expertocracy. So (similar to the way a union plumber will call in an union electrician to screw in a light bulb) experts by general agreement stick to their own areas.

Therefore, a system run by experts is a system of fiefdoms. Decisions are taken on the basis of the internal logic that best suits each fiefdom, and not necessarily any other fiefdom, much less the whole. We should not be surprised, therefore, when the system taken together often works against itself, or when individuals trying to function within the system of fiefdoms experience unnecessary and often gratuitous harm.

Experts in power do not seek answers, they know the answers. They know because they are experts. If they were seen to be seeking answers, they would not be experts any longer and their power woud slip away.

This is one of the facts that allows us to distinguish between “scientists” and “experts.” Scientists are always skeptical, always doubting, always seeking new answers that are better than the old answers. But once a scientist is elevated to the level of expert, and is placed into a position of power, all that changes. Climate scientists, for instance, are still trying to clarify the role of human activity in climate change; whereas the climate experts who issue public decrees have already made a final determination on the matter, and have declared the science to be “settled” (a concept that actually does not exist in real science). Clearly, expressions of doubt and skepticism are an acknowledgement that you do not actually have the answers. And if you do not have the answers, why should you have the power?

Experts in power almost invariably operate under a cloak of secrecy, because transparancy threatens experts in several ways. Too much openness might lead non-experts to gain sufficient knowledge to believe they can make their own decisons. Worse, transparency might cause non-experts to question whether the experts are truly acting objectively, or with perfect knowledge. Openness might make the answers the experts provide seem less oracular, and more like educated guesses or political expediencies. So maintaining as much secrecy as possible is very important to experts.

The thing that is the most dangerous to an expert in power is criticism. Fundamentally, criticism is a questioning of their expertise, that is, of their right to power. Thus, criticism is more of an existential threat to experts than it was to, say, Louis XIV, and it must be dealt with that much more severely.

What all this means is that once experts are in power, their attention quickly turns away from the subject matter of which they are supposedly experts, and toward the processes necessary for retaining power. Experts in power, therefore, quickly become primarily concerned with the process and methods necessary for holding on to power, and not with content.

Maintaining secrecy and managing critics are key to this endeavor. Their tool of choice is controlling the language. Because they are the experts, they get to say what things mean. They define terminology that is sometimes charged, sometimes soothing, sometimes complex, but that always stifles what the masses would call common sense, and that allows the experts to make their arguments in terms that are too bland or too meaningless to dispute. For extra insurance they invent lists of phraseologies whose utterance, they insist, will do great harm to society, and thus which must be strictly forbidden.

Because process is the work product of experts, they naturally create complex systems and tangled infrastructures whose purpose and organization only the experts themselves can possibly pretend to understand. The complexity itself is a powerful tool of control. Outsiders who manage to breach their walls find themselves unmanned within a structure that is incomprehensible, and whose denizens speak an alien tongue.

If secrecy, language control, and complex processes are not sufficient to protect their power, experts will of course resort to whatever means prove necessary. That prerogative, obviously, is the main advantage to having power in the first place.

If any of this is seems familiar to readers of the classics, it may be because it is a fair approximation of the methods of Machiavelli. Machiavelli was the first proponent, at the very beginning of the Age of Reason (the The Prince was written 500 years ago), of the application of reason to the achievement and maintenance of power. His methods were notable at the time for being completely devoid of underlying ideology. Pure reason, it turned out, could be applied in the service of any ideology you like.

So process became everything; content became flexible. Ignatius Loyola was effective in almost single-handedly stemming the tide of the Reformation precisely because he applied the methods of Machiavelli in the service of the Church (the content here being Catholic doctrine). His instructions to his Jesuits may sound familiar many of us who live in an era of expert control. They included an admonition to eliminate “people infected with error” from positions of authority and from the profession of teaching; orders to burn books declared heretical; orders to shun and castigate books that are not themselves heretical, if they are written by authors believed to have heretical thoughts; and orders to convene synods (official investigations) to root out errors in thought, and the people who have them.

In fact, as time went by and the processes of control became more sophisticated, content proved so flexible that it eventually became optional altogether. Progressivism – an ideology that simply aims to develop a perfect society – is so devoid of actual content (i.e., of a fixed ethical underpinning) that it has become a virtual ideology of expertise itself. Experts (the ones who can direct us to societal perfection) are not only the means, they are very nearly the primary idea of Progressivism.

So it should not be surprising that in the practice of herd medicine which will be instituted in our Progressive healthcare system, all the decisions regarding which medical services are to be supplied to members of the herd, and which are not, will be rendered only by the very best, and very brightest, experts.

Who Are These Experts, Anyway?

Many of the experts who are now running things were never trained in any particular subject matter at all (such as, for instance, classic literature or geology), but rather, were trained from the very beginning to become experts. Our leadership class tends to study disciplines like political science, or public policy, or government – disciplines whose main content is expertise itself. Our future leaders are groomed with great care and tenderness primarily in the methods and processes one must employ to function effectively as an expert – as one of those elites who will control the process of making all the important decisions for the rest of us (whatever the subject matter of those decisions turns out to be).

Despite the primary importance of expertology, sometimes one must rely on “second-level” experts, that is, on people who have some degree of knowledge or proficiency in a particular area of endeavor. This is likely to be the case when it comes time to appoint the expert panels that, under Obamacare, will be making collective decisions regarding our healthcare.

The trick for our leaders will be to identify second-level experts whose credentials, on paper at least, will allow them to be passed off as legitimate subject matter experts, but who also have the right ideas – and the right enthusiasm – regarding the great benefits of herd medicine.

I do not think it will be difficult to identify such people. Seats on the expert medical panels will be positions of the highest authority, and will thus be very desirable. And, as one might predict, these positions are being vigorously pursued. Indeed, we are seeing candidates audition for these expert panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.”

We see would-be experts vociferously extolling, in every public venue they can find, the idea of “fly by wire” medicine, whereby every decision physicians make will be determined not at the bedside by flawed individuals, but by the best and the brightest experts, acting at a distance. We see them promising to distribute rules of action based on only the best scientific evidence (“best” being determined by those selfsame experts), and insisting that the directives they hand down will be models of actionable simplicity, spelled out so unambiguously that even doctors born, raised, and trained in the Midwest or the South will be able to follow them. We see them writing scientific papers that spin the evidence in such a way as to generate conclusions which will be soothing to the Central Authority. We see them editing medical journals in order to make certain that the correct conclusions are published, and the incorrect ones are not. We see them taking control of professional organizations, and using their positions to promulgate changes in medical ethics that advance the Borg-ification of medicine, and to formally endorse Obamacare on behalf of American physicians who, for the most part, were against doing so.

These panelist-hopefuls are everywhere. They have gained great prominence within our healthcare system, and practicing physicians will be dealing with them and the consequences of their actions for many years to come. While the natural impulse of the typical American doctor might be to simply marvel at the wonder of it all, shake their heads resignedly, and go about their increasingly distressing business, it may behoove us members of the herd to take a closer look at these individuals, to attempt to understand them a little better. After all, their activities in the near future promise to greatly impact our lives and our fortunes.

So – who are they, anyway?

This, dear reader, is where the Progressive mode of thought comes in handy. I refer, of course, to the Progressive doctrine of Diversity. Divertity allows us to attribute certain stereotypical characteristics of thought and action to certain groups of people, without much regard for what individuals within that group might actually think or believe, and to do so within the perfect cover of political correctness. While in general I do not approve of Diversity as it is being practiced today, as it happens the concept might be useful in attempting to answer the question at hand.

Specifically, I refer to the theory that physicians (like any humans) tend to end up in careers that best suit their underlying personalities and proclivities, and so physicians in a given specialty will tend to think and behave like other physicians within that specialty, and unlike physicians in other specialties. If this theory has any merit (and let us call it the Diversity Theory of Physicians), it will allow us to make some generalizations about the characteristics of individuals who have chosen specific kinds of medical careers.

Let us examine some ways in which the Diversity Theory of Physicians reveals Truth. An obvious example is the specialty of psychiatry, which tends to attract doctors who are, perhaps subliminally, concerned that they are just a little crazy themselves. As it happens, it often turns out they are correct. In my own experience, and in the experience of just about anyone who has encountered more than a handful of shrinks, these fine physicians, on average, display an astonishing degree of off-the-wall psychopathology. (Not that there’s anything wrong with that.)

Emergency room doctors have short attention spans and are afraid of commitment.

Endocrinologists get their jollies sitting alone in cramped offices, studying thick volumes of laboratory data from blood tests, which they claim reflect moment-to-moment variations in hormone levels, and from this arcane evidence are able to parse out (so they say) subtle glandular difficulties. If endocrinologists were not physicians they would be accountants.

Orthopedic surgeons are former jocks, or wish they were, and the ones who end up replacing hips in old ladies instead of patrolling the sidelines at college football games are often very frustrated individuals.

Party animals who manage to gain entrance to medical school often end up as anesthesiologists.

Cardiologists would like to think of themselves as the extreme sportsmen of medicine. They like to relate to each other stories of how they put catheters into damaged coronary arteries in patients on the brink of heart attacks, and, through their skillful manipulations, open those arteries and save lives. They live on the edge, they would have us believe. But in reality their jobs are ones of relative security, predictability and instant gratification. What they do in the cath lab actually is pretty rote, and it provides them with the immediate, concrete results they crave. And any time fixing a particular artery looks a little too risky, they call a cardiac surgeon right away. This pattern of behavior suggests that their aggressive personnas and glory-seeking activities are actually masking an underlying insecurity.

It would not be fair of me to psychoanalyze all these other specialists – who have done nothing to provoke me – without also doing the same for electrophysiologists. To understand electrophysiologists, one must invoke the principle of sublimation. To sublimate is to channel an underlying negative tendency toward some activity that partially gratifies that tendency, but that is considered worthwhile by society. So, for instance, people with a tendency toward pyromania may become volunteer firefighters. People with sadistic tendencies may become prison guards. Foot fetishists can become shoe salesmen. And compulsive liars can become novelists. Who, then, becomes an electrophysiologist?

Back in the 1980s and 1990s, when I was still in practice, what electrophysiologists mainly did was to try to prevent sudden death in patients who had a high risk of dying suddenly from cardiac arrhythmias. And in order to find the optimal therapy for these patients, it was necessary to induce, intentionally and repeatedly, cardiac arrests in their patients. This was done in an effort to find an antiarrhythmic drug that would prevent the induction of cardiac arrest. This behavior we euphemistically called “serial drug testing.” Fortunately, this procedure is no longer necessary, since the implantable defibrillator is now widely available for high-risk patients.

While it has been widely remarked that those early-day electrophysiologists were a very strange group indeed, most of us who did that work ended up successfully absorbed into normal society, and today (as far as I can tell) we are for the most part generally pretty harmless. But sometimes I find myself wondering what might have become of some of us (some in particular more than others) if we had not had this remarkable opportunity to sublimate what one might speculate to be some rather unpleasant tendencies. And what is to become of that young person today who has whatever those unfortunate tendencies might be, and who, 30 years ago, might have found release as an electrophysiologist? One must not think too deeply about this.

Let us now, finally, turn our attention to those would-be experts who will soon be serving as government panelists, and see if we can decipher what kind of people these might be.

These are the kids you knew in college who studied all the time and got straight A’s in all the hardest courses, buttered up their teachers, then aced their MCATs. For them the hardest part about applying to medical school was deciding which of the many schools that accepted them they should attend. Likely, they chose one of the Ivy League ones. Their first two years of medical school – the didactic years – were much like their college experiences. They studied hard, aced all the exams, and were generally acknowledged by both faculty and peers to be at the very top of their class.

Then they reached their clinical years, and things changed. They still knew more information than anyone else, and in fact their information base continued to expand. They read all the journals, and could always quote new research findings chapter and verse. They could conjugate the Krebs cycle on demand (or whatever it is you do with the Krebs cycle), and could recite precisely which enzyme that new heartburn drug inhibited, and could say why doing so made it OK to eat pizza again.

But what they could not do was be a good doctor. They had no instinct for it. They had no ability to get patients to tell them the important information; no ability to read a patient’s facial expression, or phraseology, or body language, those signs that reveal the real truth. They had no ability to pick out and assemble the truly useful information from the flood of partial and contradictory clinical evidence that is always pouring in from several sources. When time was of the essence, they had no capacity to figure out what was going on or what they should do about it. They could not adjust to constantly changing clinical situations on the fly. In an emergency they were paralyzed, trying to match the quickly evolving situation in front of them with the static words on the printed page. And often they were klutzes.

They were perfectly cut out to learn medicine, but lousy at actually doing it. What was worse, some of their colleagues who were mediocre in the book-learning department suddenly blossomed into highly competent clinicians on the wards, and quickly became recognized as rising stars by attending physicians, while they themselves were repeatedly chastised, or ignored.

And it just wasn’t right. It just wasn’t fair. They had worked harder than everyone else, had twice the brains of their colleagues, and had learned the material three times as well. But the way God set it up, they just weren’t good doctors.

Many of these unfortunate souls quickly left clinical medicine, and branched off into research, academics, or administration. Most of them did quite well for themselves, because they really are very smart. But they never really got past their frustration and anger over their unjust failures on the clinical wards, a place where their obvious inferiors lorded it over them. They have now spent years engaging in cognitive dissonance, convincing themselves that their apparent failure was an illusion, merely a sign of having been subjected to the anti-intellectual, shoot-from-the-hip, do-it-quickly-and-make-more-money environment that is American healthcare. After all, how could they be sub-optimal physicians when they are clearly far more intelligent and knowledgeable than the supposed “stars?” If the healthcare system had been arranged differently, in such a way as to make the cowboys behave the right way, they would have proven themselves to be the best clinicians in the land. It is a bitter, bitter pill.

These are the men and women, I submit, who are chomping at the bit for the opportunity to sit on the Central Authority’s expert panels. They would dearly love the chance to utilize their superior intellectual firepower, to distill the clinical research data, to digest it painstakingly and thoroughly (not haphazardly and on the fly like those others), to put down on paper the right way of practicing clinical medicine – and to have the authority to do it in such a way (backed up by the full force of the government) that those lesser doctors will have to do it their way, at long last.

The point of all this psychoanalytic guesswork is to suggest that the expert panelists, even the expert panelists who are physicians, will have no sympathy for the idea that the practice of medicine should be individualized to any degree at all, or that skill in “reading” patients’ faces, or instinct, or (above all) experience, or any other non-objective and irrational methodology, should play any role whatsoever in the practice of medicine. The idea of individualizing medical care, rather than practicing by formula from a book, is what caused these people the most uncomfortable moments in their professional lives. Far from being sympathetic to the idea, they will probably be more hostile to it than the non-physicians on those panels. When some non-physician panel member suggests that, perhaps, we should give the doctor a little more leeway on this or that particular issue, these expert physicians will speak up and say, “Listen. I’ve been there and you haven’t. These doctors don’t need any more rope, unless it’s for us to bind them even tighter.” They were themselves shown no quarter, in the tough arena of clinical medicine where outcomes (and not process or book knowledge) is the only mark of success, and they will offer none in their turn.

I obviously cannot prove any of this. I am merely giving an educated guess based on my own personal observations and prejudices, having observed many of these whiz-kids in my 25 years of teaching medical trainees, and watching where they wound up. I could, of course, be wrong.

I hope so.

In any case, having considered the general question of the advisability of placing experts in positions of power, and having speculated on the kind of person who most likely will end up on the Central Authority’s expert medical panels, let us now take a brief look at the damage experts can do to the public welfare when they are placed in charge of health policy. Unfortunately, we already have a few striking examples we can study. And studying these examples might be useful for those of us in the herd, so we have some small idea of what to expect.

Medical Experts and Dietary Fat

The Central Authority is quite exercised at the moment over the obesity crisis they perceive – a crisis which we in the herd have brought upon ourselves through our sloth and gluttony, to the great inconvenience of our enlightened leadership. What the Central Authority fails to note (publicly at least) is their own central role in creating the obesity problem. They did it with their war on dietary fat.

An association between dietary fats and coronary artery disease was first noted in the 1950s. In 1957, the American Heart Association (AHA) published its first, tentative recommendations for limiting the consumption of saturated fat. The recommendations were pointedly aimed only at people who had a strong genetic predisposition to heart attacks or strokes, or who already had heart disease. An accompanying editorial by Herbert Pollack, in the August, 1957 issue of Circulation, specifically warned against the widespread application of any policy restricting saturated fat:

“Altering the dietary habits of a large population group is fraught with a great many dangers. Our knowledge of nutrition is not sufficient at this time to anticipate what ultimate results would happen if the public were encouraged to alter radically their basic dietary patterns.”

The AHA’s recommendations regarding saturated fats received sparse attention for nearly 20 years. Then in 1977 our government, having won the war against hunger, turned its attention to the opposite problem (where it remains to this day). At that time, during another notably Progressive administration, the Senate’s Select Committee on Nutrition and Human Needs, chaired by George McGovern, nationalized the question of avoiding dietary fat. After holding a series of hearings on the relationship between fat consumption to heart disease, the Committee published the first “Dietary Goals in the United States,” advising all Americans to cut back on all fat consumption. With this report, the US government for the first time officially endorsed a particular type of diet – a low-fat diet – for everyone.

The Committee took this stance (on behalf of the Central Authority) despite warnings that were raised at the time by several nutritional scientists, who pointed out that the data establishing a causative role of animal fats in coronary artery disease was circumstantial at best, and further, noted that even if saturated fats turned out to be “bad,” there were plenty of other fats that were healthy, and which Americans should take pains to consume. But the official experts who were advising the Committee strongly objected to any such warnings, and insisted that the science on the matter was sufficiently settled to justify universal dietary guidelines for the whole population. Furthermore, they said, trying to educate the bovine masses on the differences between good fats and bad fats (assuming there was such a thing as good fats) would obviously be impossible. The public was too dim for such subtleties. The Senate Committee followed their experts, because experts know the answer. Accordingly, Committee opted for the far-simpler “fat is bad” message that you can sell even to gun-toting Bible-thumpers.

The anti-fat movement got its next big push in 1983, when the Framingham study published a landmark paper tagging obesity as an important risk factor for cardiac disease. This new evidence allowed the experts to reason thusly: If the people are getting fat, it must be because they are eating too much fat. It is therefore plain that that low-fat diets will prevent heart disease both directly (as they had already decreed in 1977), and now, indirectly (by preventing obesity).

Accordingly, in 1984 the NIH assembled by a group of scientists and experts which subsequently issued a Consensus Statement entitled “Lowering Blood Cholesterol to Prevent Heart Disease.” This document was an all-out, government-sanctioned, expert-led attack on dietary fat. Again, several of the scientists the NIH had invited to the conference argued that there was a lack of convincing evidence demonstrating that low-fat diets would be healthful. But the true experts, seeing an epidemic of heart disease which must surely be due to fatty diets, carried the day, and the Consensus Statement was voted into publication.

Shortly thereafter the AHA also endorsed this Consensus Statement. Finally, everything was in place for a major campaign across the land for low-fat diets for everyone.

The great low-fat diet era was ignited. Prestigious medical organizations spurred a campaign of public service announcements and media blitzes promoting the need to avoid fats in the diet. Influential magazines (that is, magazines read by women) began a prolonged onslaught of low-fat diet tips, articles, and human interest stories emphasizing the deadly nature of dietary fat. The food industry, which was at first very skeptical (just like the banks were when subprime mortgages were initially foisted upon them by government policy), finally jumped in with both feet (again, like the banks). A massive new product line of low-fat and no-fat snack foods was invented. These, of course, were just packed with carbohydrates, and also with the supposedly “healthy,” man-made trans fats (more on this in a moment). This tsunami of change in America’s processed foods has been referred to as the “Snackwell phenomenon.” And, as if to put an exclamation point on the utter goodness of it all, the AHA, tapping into a lucrative new revenue source, began officially certifying these low-fat, high-carb products (including items such as Frosted Flakes and Pop-Tarts) as being “Heart Healthy.”

Americans, however, are filled with the milk of human nature. So they largely ignored the ubiquitous pleas to abandon their burgers, pizza and tacos in favor of broiled, skinless, sauceless, saltless chicken breasts and broccoli. But they did begin scarfing up all those the new-age low-fat snack foods in massive quantities, having been assured that, as long as the snacks contained no fat, they could eat as much as they wanted.

There are a few physiological facts about dietary carbohydrates that the experts chose to largely ignore during the low-fat era. First, the body greedily converts dietary carbohydrates into massive stores of adipose tissue, so indeed you can readily become fat by eating carbs. Second, gorging on the refined carbohydrates found in these new “healthy snacks” causes big spikes in insulin levels (insulin being a key factor in converting excess carbohydrates to fat). When the insulin levels suddenly drop a couple of hours later, that drop produces insatiable hunger. So, two or three hours after enjoying a fat-free Pop-Tart or a Snackwell cupcake, one finds oneself desperately ripping through the cupboards to find another carbohydrate fix. By thus inducing a continuous-snacking mode, the new high-carb snack foods increased the overall caloric intake of many of the people who began eating this stuff, far beyond the additional calories listed on their labels. Third, diets high in refined carbohydrates increase triglyceride levels, reduce HDL cholesterol (“good” cholesterol) levels, and in general create lipid profiles that are likely quite damaging to the arteries.

So, while few people actually stuck to a strict low-fat, controlled-calorie diet (and to this day we still don’t know whether doing so is actually a particularly good idea), many more people became addicted to the AHA-endorsed refined carbohydrates that were officially associated with low-fat diets, and as a result, they became obese.

It has only been in the past ten years or so that the low-fat dogma has begun to moderate, largely thanks to the (now mercifully faded) low-carb craze that struck at that time. We now hear somewhat more reasonable advice about good fats and bad fats, and good carbs and bad carbs. But much of the damage has been done. The damage occurred because public health experts made a conscious decision to change Americans’ dietary habits, despite clear warnings that the evidence for doing so was shaky at best. At least partly because of the major push for low-fat diets, we Americans are fatter and less healthy today than we used to be.

The Central Authority’s low-fat diet policy amounted to a massive public health experiment, with the research subjects being us. Our government and our expert-led medical organizations have yet to apologize for subjecting all of us to this travesty.

The Trans Fats Two-Step

In the 1980s, coincident and associated with the adoption of the low-fat diet policy, experts also saw to it that the “deadly” saturated fats in processed foods were replaced with the completely benign, inert, man-made variety of fats known as trans fats.

Almost all the trans fats we find in our in food is man made. Trans fats come from an industrial process that partially hydrogenates unsaturated vegetable oils. The process of partial hydrogenation solidifies liquid vegetable oils, and makes them stable for long periods of time. (Liquid vegetable oils go rancid relatively quickly, and are not suitable for processed foods with a long shelf life.)

For many decades trans fats in American diets were largely limited to the use of Criso, a shortening used for baking. Trans fats did not replace saturated fats in processed foods, for the most part, until the 1980s. It happened in the 1980s, of course, because of experts.

When the Central Authority declared its holy war on fats in 1984, an organization of food experts and food activists dedicated to stamping out saturated fats – the Center for Science in the Public Interest (CSPI) – took that as a signal to launch a major (and apparently well-funded) campaign to coerce the food industry to abandon saturated fats in all processed foods, in favor of trans fats. Trans fats, the CSPI experts declared, were entirely harmless, and by insisting on using deadly saturated fats instead of trans fats, the food industry was killing us all. The food industry largely capitulated to the CSPI’s campaign in 1987, and rapidly moved almost entirely to using trans fats.

The actual safety of trans fats in humans, however, was questionable even then. Indeed, because certain scientists were attempting to call experts’ attention to data suggesting that trans fats are actually quite harmful to vascular health, in 1988 experts at the CSPI felt compelled to write a major defense of trans fats in an article called “The Truth About Trans.” This article strongly defended trans fats as being completely safe for humans, despite growing warnings to the contrary. The CSPI widely distributed this article to experts and decisionmakers (such as legislators), and for a year or two the organization seemed very satisfied with itself.

Unfortunately clinical data continued to accumulate showing that trans fats, far from being benign, likely caused more vascular damage than saturated fats. By 1993 the CSPI could no longer ingore this mounting evidence, and did a complete about-face. It launched an indignant campaign demanding that the food industry remove these deadly trans fats from all food products. Their turnaround was artful. It was accompanied by a whitewash of the CSPI’s very recent history relative to trans fats (i.e., that they were largely responsible for the widespread use of trans fats in the first place). A sympathetic press (sympathetic because the CSPI was, as always, attacking evil corporations for killing Americans in the name of profit) let them get away with their revisionism.

We can give the CSPI experts credit for being willing to shift course so soon after their seminal victory. But we should also note that they displayed stereotypical expert behavior during this episode. In 1987 they insisted they had the right answer, despite warnings from scientists who had credible evidence that their “answer” was wrong. And, once the experts at the CSPI reversed course in 1993, they never again acknowledged their pivotal role in having trans fats placed in our food supply, nor did they express any remorse for it. Likely, they never felt any remorse. Rather, they almost certainly believed they were successful both times – when they wanted trans fats placed into the food supply, and again when they wanted them removed. For experts, process (and not content) is the important thing. And the process worked well on both ends of the trans fats episode.

This orientation toward process is very convenient for experts. When the content of their endeavors turns out to be a horrible mistake, they simply re-orient their processes and move on as if the mistake had never happened. To outsiders it appears that when you are an expert, history always began 10 minutes ago. But to the experts, their history is simply a parade of one success followed by another.

Salt Wars

The misbegotten experiments that health experts foisted upon all of us by pushing low-fat diets on us, and by demanding that trans fats be used in processed foods, cost billions of dollars, needlessly transformed large swatches of American industry, and likely produced significant harm to the citizenry. Far from being chastened, however, the experts are determined to continue inflicting us with their expertise, to the great benefit of us all.

Accordingly, without missing a beat, these same experts have now launched yet another experiment that recruits each of us within the herd as unwitting research subjects. And once again, it is an experiment that has a realistic chance of producing serious harm (despite the experts’ assurances that the science is settled and that only good can come of it). I speak, of course, of the new dietary guidelines regarding sodium.

Those new guidelines have been promulgated on the basis of these established “facts:” Sodium is bad. We all get too much of it. And if we restricted our salt intake to a much lower amount than we are likely getting today, we will all become healthier and live longer. Relying on this received wisdom, the new guidelines call for us to cut back to 2300 mg of sodium per day – unless we are 51 or older, or African-American, or hypertensive (and the majority of Americans fall into one of these three categories), in which case we are to restrict our sodium to 1500 mg per day.

For anyone who strays from eating only fresh fruits and vegetables, this kind of restriction is likely to prove a challenge. A nice bowl of dry cereal, for instance, even before you add milk, may give you up to 1000 mg of sodium.

Some Americans might consider such severe restrictions to be merely a statement of an ideal, as if the Central Authority were saying, “It sure would be nice if you could keep your sodium intake down to these levels. It might do you some good. So please do the best you can.” But this is not at all how the Central Authority is viewing the matter.

The experts over at the Institute of Medicine, for instance, recently published (in conjunction with the new Guidelines) its “Strategies To Reduce Sodium Intake In the US.” Noting that public health experts have tried in vain for decades to get Americans to cut back on salt, the IOM says the time for persuasion and education has passed. The great unwashed are proved to be recalcitrant, yet again, to reason and science. It’s time to take the gloves off. So the IOM calls for the US government (specifically, the FDA) to use its regulatory firepower to enforce – once and for all – the kind of sodium restriction that the public welfare demands.

Specifically, the IOM calls for the FDA to reclassify “salt” from a food ingredient categorized as GRAS (“generally regarded as safe,” i.e., items which have been used for millennia in food preparation without regulatory oversight, such as pepper, parsley, or vinegar, and which are accepted as being harmless), to a “food additive” (i.e., a substance which is certifiably harmful, and for which strict, enforceable rules must be promulgated regarding its use). Re-classifying salt as a food additive will give the FDA the authority it needs to enforce its usage (as with any other regulated substance) in the food processing industry, in restaurants, and even, one must assume, in the home. With this new designation, the FDA (and other government agencies) will be able to deploy whatever regulatory and enforcement muscle they must, in order to assure that the Guidelines for sodium are at last realized.

This is serious stuff. The Central Authority seems dedicated, as never before, to actually implementing a significant sodium restriction for all of us within the teeming masses. All, of course, for our own good.

You might think, if you have not been paying attention, that in order for experts to insist on such a severe across-the-board sodium restriction, the scientific data to support this action must be pretty airtight. But if you have been paying attention, you will not be surprised to hear that the actual advisability of restricting dietary sodium across the entire population is anything but settled. In fact, it remains very controversial among scientists.

There are at least three outstanding questions regarding the advisability of a universal salt restriction. Until these questions are addressed, the implementation of a generalized and severe sodium restriction across the population would seem, to any objective observer, to be quite ill-advised (and, of course, incredibly arrogant).

1) Does Sodium Restriction Really Do Any Good?

Books have been written addressing just this one question. Here I will simply summarize the problem.

The question hinges on the relationship of salt intake to blood pressure – that is, does higher salt intake cause the blood pressure to increase? This turns out to be a difficult question to answer with any scientific precision. The studies are difficult to conduct, and difficult to interpret. Accurately measuring sodium intake in any sizable population of patients is nearly impossible; and even measuring blood pressure (which varies tremendously from minute to minute, depending on activity, stress, and many other factors) in a reproducible way within a population of patients is extremely difficult.

Scores of studies have been conducted to try to address this question. And one can assemble from these a large group of studies which will show that salt intake correlates nicely with blood pressure. On the other hand, one can also assemble from these a large group of studies that shows it does not. And for decades, the salt vs. blood pressure question has been divided into two camps, each of which have major conflicts of interest*, and each of which invariably point to only those studies that tend to support their point of view.

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* In one camp are the National Heart, Lung, and Blood Institute, the National High Blood Pressure Education Program, the Institute of Medicine, and academic experts on hypertension whose careers have been based on funding from these organizations, and whose reputations and academic standing rely on sodium intake being a major determinant of blood pressure and health. In the other camp are the Salt Institute, the big manufacturers of processed foods, and sundry academic experts on hypertension whose careers have enjoyed funding from these sources. Take your pick.
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My own reading of the medical literature suggests that the population itself is divided into (at least) two types of people with regard to sodium and blood pressure: “salt sensitive” people, in whom sodium intake significantly influences blood pressure; and “salt insensitive” people, in whom it does not. Most folks appear to fall into the latter category. So, if we really wanted to use salt intake as a tool for controlling the populations’ blood pressure, it might be a good idea to recommend salt restrictions for “salt sensitive” individuals, but not for the majority. But it is inconvenient and impractical to determine people’s salt sensitivity, and besides, doing so would go against the principles of herd medicine. So the experts, in their wisdom, appear to have determined that the best way to restrict sodium in the people who are salt sensitive is to restrict it in everybody.

To see just how deeply politics is involved in the salt controversy, I highly recommend an article called “The (Political) Science of Salt,” by Gary Taubes, which appeared in 1998 in Science, and which outlines the incredible machinations that have been employed by the various interested parties in interpreting some of the complex studies that have attempted to correlate salt intake with blood pressure.

Our imaginary objective observer can only conclude that, at the very least, this is not a settled question.

But even if it were a settled question, and sodium intake did indeed correlate nicely with blood pressure across the whole population (and even legitimate herd medicine would require this minimum criterion before enforcing a universal sodium restriction), the degree of blood pressure reduction predicted by even the most vociferous sodium-restriction-enthusiasts, even employing drastic sodium restrictions, seems trivial. Most experts predict an average reduction in blood pressure of only 1-2 mmHg. The experts defend their universal salt restriction by arguing that this tiny reduction in blood pressure, on a worldwide basis, would save over 100,000 lives per year. But this argument is (scientifically speaking) hogwash. Such estimates are merely calculations made from strings of assumptions piled upon assumptions, and have little or no bearing on reality.

The fact is that we just don’t know what effect it would have on the population’s health to significantly restrict salt intake in everybody. We don’t know the magnitude of blood pressure reduction it would achieve, or the improvement in clinical outcomes that would follow such blood pressure reduction.

We could find out if we really wanted to – by doing a large, randomized clinical trial to test the hypothesis. But the experts have determined that such a randomized trial is not necessary because the science is settled, and besides, time is of the essence. (Astute readers will have noticed that when you are an expert, the science is always settled, and time is always of the essence.)

Our health experts would rather conduct a non-randomized experiment that enrolls every living American as an unwitting research subject. Then, in a couple of decades (reminiscent of the low-fat diet “experiment”), maybe we could figure out how it all worked out.

2) Does Sodium Restriction Cause Harm?

Here is a question that the health experts, who have revealed to us that salt restriction is an unalloyed good, really object to. For it questions their infallible pronouncements. It is, indeed, criticism. So they tend to get downright nasty when anyone brings it up.

But, as it happens, it is a legitimate question.

Sodium is extremely critical for any living creature. For any living cell to function normally, it must exist in an environment that contains, within a narrow range, just the right concentration of sodium. Consequently, living beings have evolved a complex series of mechanisms to assure an adequate sodium concentration under any and all circumstances. So, if animals are made to survive on a severely sodium-restricted diet, these homeostatic mechanisms are called into play to restrict the loss of sodium from the body. The stimulation of these sodium-retaining mechanisms can have many secondary effects.

In states of sodium depletion, tissues are more susceptible to injury from ischemia (lack of oxygen), a condition seen in heart attacks and strokes. Kidney damage caused by many types of medication will occur much more readily in states of sodium depletion. The way the kidneys handle various drugs is also altered when sodium intake is reduced, leading to potentially harmful changes in the blood concentrations of certain medications. The renin-aldosterone system is activated under salt restriction, which can have several adverse effects. (In fact, a major therapy for several medical conditions, such as heart failure and – ironically – hypertension, centers around suppressing the renin-aldosterone system.) Adrenaline levels and LDL cholesterol are increased when sodium is restricted. And at least one study, disturbingly, has correlated sodium restriction with an increase in cardiovascular mortality.

Calling attention to these kinds of findings just makes the sodium-restriction experts angry, and they usually respond by pointing out that so-and-so got a grant from the Salt Institute. (As noted, there are conflicts of interest on both sides of this fight.)

In 2011 alone, five new studies were published which question the safety of salt restriction for the whole population. One in particular, published in December 2011 in the Journal of the American Medical Association, suggests that when you compare cardiovascular events (such as heart attack and stroke) to sodium intake, the incidence of those events follows a “J” curve. That is, cardiovascular events are lowest at an “optimal” level of sodium intake. But if sodium intake goes above that optimal level – or if it goes below it – the incidence of cardiovascular events increases.

According to this study, the “optimal” level of daily sodium intake is 4000 – 5999 mg of sodium per day. Cardiac outcomes worsen for those with sodium intakes above or below those values.

As we have already noted, health experts are insisting on sodium intakes far below the 4000 mg threshold. Their recommendations would place everyone on an unenviable portion of the J curve, and (if this new study has any merit) would risk exposing all of us to an excess of cardiovascular disease.

Whenever a study appears that calls into question the advisability of a universal sodium restriction, the experts are quick to respond. In response to the “J curve” study, Heartwire (an online newsource for cardiologists) elicited the following response from Dr Graham MacGregor of London’s Wolfson Institute of Preventive Medicine (and a major sodium restriction guru): “[These new studies] are a minor irritation that causes us a bit of aggravation, and we have to talk to journalists about it, because they are not interested in news saying salt is dangerous.” MacGregor went on to insist that the need for a global sodium restriction remains a settled issue: “What [these irritating investigators] fail to understand is that the FDA is not asking for evidence about why salt should be reduced, they are asking how it should be reduced.” So new data is not needed, nor will it be heeded. It is all a settled matter.

At the end of the day, we have conflicting sets of observational data that can be interpreted to say different things. It may be true that a severe population-wide salt restriction would be a huge boon to mankind. But it may also be true that it would harm more people than it would help – or that it would harm and help about the same number, so the overall results would be the same.

The fact is, we just don’t know.

3) Is It Even Possible To Change Sodium Intake By Public Policy?

As we have noted, maintaining the proper sodium concentration in tissues is critical to life, so living creatures have evolved a complexity of mechanisms to assure that the concentration of sodium in the body remains within the proper range.

Among these mechanisms, it now appears, is an inherent “sodium appetite” enjoyed by all humans and all animals, an in-born mechanism that determines how much sodium an individual will ingest each day to help keep just the right sodium “set-point.” This sodium set-point is maintained by a complex neural network that is still being sorted out, involving several regions within the central nervous system, as well as inputs from the peripheral tissues. The bottom line is that one’s own physiology naturally regulates one’s sodium intake to satisfy the body’s needs.

Furthermore, studies of sodium intake across a wide array of human populations, living under a wide variety of conditions and dietary constraints, also show that the range of salt consumption humans take in to achieve their set-point is remarkably universal, and is maintained within a fairly narrow range. That is, not only do humans consume the proper amount of sodium as determined by the body’s needs, but across the diversity of humanity that “automatic” sodium intake is maintained within a remarkably fixed range. (Sodium intake moves within that range to maintain the body’s proper sodium set-point.)

As it happens, the lower limit of that universal, naturally occurring, “optimal” range of sodium intake is roughly 2300 mg/day.

By pure coincidence, this natural lower limit, determined by our physiology, is the same as the the upper limit our Central Authority would have many Americans consume. (The rest of the Americans will be consuming only up to 1500 mg/day, which is far below the natural lower limit.)

In other words, by decree, our government would have every American consume an amount of sodium that is below the optimal range (or at best, barely touching the optimal range), as determined by actual human physiology. Almost by definition, anyone living under the recommended guidelines would likely be unable to maintain proper sodium concentrations through sodium intake alone, and would need to recruit the secondary, sodium-retaining, potentially-harmful physiological mechanisms (such as the renin-aldosterone system) to keep sodium concentrations at an adequate level.

Furthermore, it seems to me that if we have a deep physiological need to satisfy our “sodium appetite,” and if the only food we can get will be (by the Central Authority’s decree) low-salt, then the only way we can satisfy our sodium appetite will be by eating more of it. In other words, an enforced policy of sodium restriction seems likely to worsen our obesity epidemic.

It is apparent that even if a universally-applied policy of significant sodium restriction was proved to be safe and effective, it may not be possible to make people comply with such a restriction. This kind of restriction will be fighting our inherent “sodium appetite” that has been forged through millions of years of evolution. This kind of restriction would appear to fly in the face of our human physiology.

We need salt, dear readers, we truly do. The only reason the Founders did not include an additional paragraph in the Second Amendment (to the effect that, “A palatable diet being necessary to the health and well-being of a free People, the right of the People to bear salt shall not be infringed,”) is that it never occurred to them that any government, anywhere, would ever attempt to restrict such an inherent physiological necessity.

Of course, anyone who has observed the Central Authority at work – as it attempts to implement policies that require fundamental changes in human nature, or that require the repeal of the basic laws of economics – should not be surprised at the notion that our Progressive leaders would also try to repeal human physiology.

We have already seen the harm that can be done when we allow public health experts to launch major, population-wide dietary changes, before adequately studying what their effects will be. Especially given the increasing evidence of the harms that might be done by it, we are nuts if we allow the arrogant expert class to enforce a salt restriction program on all of us, before we have completely studied its likely results.

A Tyranny of Experts

A major thrust of our new healthcare system is to implement herd medicine. Fundamentally this means empowering the experts to practice medicine, from a distance, upon the whole population. Urging caution or even a certain amount of circumspection on this newly-empowered expert class, as it begins exercising its much-sought and hard-won right to dictate American healthcare on a collective basis, is destined to be a futile exercise.

The health experts hold the high ground. For they are experts in a system that, if it worships anything, worships experts. They are the ones with the answers. Woe unto anyone who would stand in their way!

They are the ones who will give directives to doctors on the front line, and direction to the sundry health-related agencies of enforcement wielded by the Central Authority. Once they have formed an expert opinion the issue is settled, and it immediately becomes time – backed by the power of the Cenral Authority – to sweep aside any opposition, and implement the process.

As long as the process itself is successful, actual results visited upon members of the herd are not that important. Therefore, as far as the experts are concerned, their implementation of low fat diets was successful. Their incorporation of trans fats into our food supply was successful. With these fresh triumphs under their belt the experts have been validated, and they move confidently ahead to implement their new sodium restriction policy.

Armed with their infallible answers, they know only one word (a word we have heard before, and one that is being adopted again as a call to arms): “Forward!” If the herd suffers because of it, the experts will pretend not to notice.

For the herd will always be there, and the experts can always try again.

This is Chapter 9 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.
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Chapter 9 – An Introduction To Herd Medicine

Farmer Jones has 10,000 head of cattle in his beef herd. He prides himself in staying up to date on all the latest methods, so he knows that adding a certain antibiotic to his cattles’ feed will reduce the incidence of intestinal infections, and will increase his annual overall yield, measured in pounds of beef, by 7%. He also knows that, unfortunately, roughly one in 200 of his cattle will experience a likely fatal allergic reaction to the antibiotic. It is possible to do a blood test to determine which specific members of the herd are allergic, but the test itself is quite expensive, and the logistics of separating the allergic cattle at feeding time and providing them with their own antibiotic-free feed would be so costly it would entirely wipe out his potential savings. What should Farmer Jones do?

Obviously, the cost-effective solution is for Farmer Jones to give antibiotic-treated feed to all his cattle, accepting the loss of a few head as the necessary price for an impressive overall gain in productivity. He would be an ineffective and incompetent rancher indeed if he were to pass up this golden opportunity to achieve cost-effectiveness.

The Hazards of Herd Medicine

If you are a patient or a potential patient (and who is not!), you ought to be especially concerned about two particular hazards that are intrinsic to herd medicine. First, as demonstrated by Farmer Jones, medical decisions that are made on a collective basis rather than on an individual basis may succeed in improving the overall outcome for the herd, but often only at the cost of doing predictable – and avoidable – damage to certain individuals within that herd.

Second, since it is the overall health of the herd which is important, there will always be individuals within the herd whose very existence is seen by Farmer Jones as counterproductive. Individual cattle that are too scawny, too old, or are otherwise unlikely to prove profitable, are still consuming valuable resources and taking up valuable space. So under any system of herd medicine there will always be a natural temptation to cull instead of cure certain inconvenient individuals.

It is extraordinarily politically incorrect to mention this second point, and so I must apologize right away for having done so. Sorry.

In fact, Obamacare, so far, seems to have taken no overt steps in the direction of actively “culling the herd.” But the history of Progressivism, sadly, is not reassuring in this regard. Early Fathers (and Mothers) of Progressivism enthusiastically embraced eugenics as an attractive, science-based method for reducing the sort of undesirable citizens who so obviously hinder the achievement of a perfect society. Certain Progressive societies – led by doctors – have conducted the “humane termination” of people with various disabilities. And collectivist governments (admittedly usually out of frustration at the recalcitrance of human nature than out of any scientific zeal) have been responsible for the deaths of millions of people over the last century. So, if only to keep on the safe side, we members of the Obamacare herd ought to remain alert to any tendency toward culling behaviors. If our Progressive friends are as filled with the milk of human kindness as they insist, our vigilance in this matter may waste some of our time, but otherwise should do no harm. And accordingly, to help focus our vigilance (in order to render it more cost-effective), in later chapters I will point out certain aspects of American healthcare that seem particularly likely venues for culling activities.

In this chapter, however, I will concentrate on the less sinister but more universal hazard inherent to herd medicine – causing predictable and avoidable harm to individuals by insisting on making medical decisions collectively.

A Herd Medicine Hypothetical

Let us imagine that a large clinical trial has shown that a new cancer drug increases the mean survival in women with metatstatic breast cancer by three months. Unfortunately, the drug also causes some very nasty side effects, including some that can be fatal. And again unfortunately, this is one of those fancy designer drugs that cost over a billion dollars to develop, and is very costly to manufacture – so it is quite expensive.

A panel of experts, after carefully studying all the evidence, concludes that, given the relatively short improvement in mean survival, neither the risk/benefit ratio nor the cost/benefit ratio justifies approving the drug. The news media, while expressing sadness and compassion for breast cancer patients, solemnly concurs that the experts, of course, are right – that, while the drug has shown promise, it’s just not effective enough to justify the risk of side effects, or the cost of the drug. So better luck next time, with the next drug.

I think we must agree that it cannot be society’s duty to buy this new drug for all women with breast cancer. Under any publicly funded healthcare system that is run in fiscally sound manner (at least sound enough to avoid causing a catastrophic financial collapse), some line will need to be drawn, somewhere, regarding what expenses public funds can bear. And very possibly, a cancer drug that only extends the mean survival by three months may not make the cut.

In Chapter 4 we discussed the four possible methods for running a fiscally sound healthcare system. If we were under a Method Three healthcare system, where public spending is strictly limited but where individuals have the option of supplementing the public system with their own private insurance products, or even paying for desired healthcare services themselves, then many individuals would still have access to treatments like this new cancer drug, if they wanted to try it.

But under a Progressive, Method Two healthcare system, public funding is all there is. In this case one centralized coverage decision must fit all, and the result is herd medicine. Under herd medicine the new cancer drug cannot be approved, for anyone, once a panel of experts determines that its herd effect is insufficient to justify approval.

But determining the herd effect of a therapy (i.e., the average response to that therapy across a herd of patients), does not really tell the whole story.

Going back to our hypothetical, if you look at what actually happened in the clinical trial with our imaginary cancer drug, it turns out that very few of the women with breast cancer actually experienced three additional months of survival. Instead, some had a truly remarkable response to the drug, and are still alive a year or more after their predicted demise. In fact, it appears that a few might even have been completely cured. Some women, on the other hand, had very bad experiences with the drug, and side effects hastened their deaths. When you average all of these responses together, you get a mean benefit of three months.

But “three months additional survival” is not actually what we would expect to happen with most individual women who take this drug, and in fact this happened with relatively few of them.

In general, the reason people with cancer subject themselves to the ravages of chemotherapy is not to gain a few more weeks of life. The chemo itself often produces several weeks where life is barely worth living, so that would be a bad trade. Rather, they subject themselves to chemo on the hope – often a slim hope – that by doing so they are gaining some realistic chance at surviving for a long, long time.

If you were to give women with metatstatic breast cancer – an incurable disease that invariably causes death – the option of taking our hypothetical new cancer drug, some would opt for it and others would not. But in making their decisions, most of these women would not be thinking about the average of three additional months. Rather, most would be considering the fact that this new drug offers them some chance to beat back their cancer for substantially longer than that. They would be hoping to beat the average. They would be making the same calculus that cancer patients always make.

This new cancer drug represents a new chance at long-term survival, and faced with a fatal disease that is difficult to treat, taking that chance would have been a reasonable choice for many women – even though the drug produces only a tepid herd effect.

Herd medicine removes this option. When our hypothetical panel of experts decides not to approve this new drug – for anybody – what they have concluded is that, because the drug does not produce a sufficiently favorable effect across the herd, individual women should not have the option of using it. This is the only thing expert panels under a herd medicine paradigm can do. They cannot deal in nuances. They must determine whether a new therapy merits application to the entire herd, or to nobody.

Furthermore, if the answer is “nobody,” then the message the experts must convey – the only acceptable message they can convey – is that the new therapy simply doesn’t work. Either they will say it is ineffective, or that its modest average effect is completely negated by the risk of side effects. They cannot let on that the actual data suggests that some individuals will have a truly remarkable benefit from the drug, and that on an individual basis, deciding to take the drug despite the risks would not be unreasonable.

It is worth noting that as a general rule, progress in cancer treatment has been a slow, painful and incremental process. Very few therapies have been devised that have single-handedly led to major gains in survival. Rather, progress has come from a long series of small steps – improving the average survival by three months with this drug regimen, then adding another six months with another drug regimen, and so on. Once expert panels begin deciding that adding another three (or six, or nine) month increment to the average survival of the herd does not meet the threshold for approval – that is, once it becomes evident that only “home run drugs” are sure to be approved – then drug companies will become quite reluctant to invest in the development of new cancer drugs. And medical progress will slow drastically.

Herd medicine will remove individual choice, will take away hope, and will stifle the slow, steady progress we have made in treating some of the most deadly diseases we face.

Patients, Widgets and the Axiom of Industry

The hallmark of herd medicine is that it systematically and officially devalues the worth of the individual, essentially declaring that patients can be treated all alike, as if they are interchangeable members of a homogenous group. This devaluation of the individual, however, was not produced out of whole cloth by the Obamacare legislation. Rather, it is something that has been in the works for several decades, the natural, evolutionary result of a philosophy of healthcare that was all the rage until just a few years ago, but which – mysteriously – we seem to hear very little about these days. I refer, of course, to managed care.

Like many of the travesties that have taken place within our healthcare system, managed care began with a pretty reasonable idea; namely, to apply certain management principles to the healthcare system that have been used successfully in other industries, thereby injecting logic, organization, and accountability to what had been a bastion of disorganization and inefficiency.

The unifying idea behind managed care boils down to one word: standardization. Standardization is virtually a synonym for industry. In industry, standardization is the primary means of optimizing the two essential factors in any industrial process: quality and cost.

This proposition can be stated formally as the Axiom of Industry:

The standardization of any industrial process will improve the outcome and reduce the cost of that process.

If you had a widget-making factory, you would break your manufacturing process down into discrete, reproducible, repeatable steps and then optimize the procedures and processes necessary to accomplish each step. To further improve the quality of your finished product (or to reduce the cost of producing it), you would reexamine the steps, one by one, seeking opportunities for improvement. You would need to understand the process thoroughly, and you would need to collect data about how well the process works. But with the right information, you could almost certainly identify a few minor changes to improve the manufacturing process. The beauty in such a system is that you have only to make one change — to the process itself — and every widget that comes off the line after you make that change will be improved.

So standardization is good. It leads to higher quality and lower cost. Conversely, variation is bad. It reduces quality and raises cost.

Proponents of managed care argued that standardization should be just as useful in healthcare as it is in other industries. As medical care has traditionally been individualized, highly variable, and without any semblance of standardization, there must be a huge opportunity to improve the processes of care and to make them both cheaper and more effective. There is obvious merit in such an idea.

Perhaps the most direct, and the most successful, application of managed care practices to modern medicine was the adoption of “critical pathways” in the 1990s.

Critical pathways are blueprints for delivering standardized care to patients with specific medical problems. Consider a critical pathway for hip replacement surgery. The critical pathway is a specific schedule laying out which services are to be provided for the patient and when, from the date of hospital admission until the date of discharge (which is, of course, predetermined). Checklists are created itemizing which laboratory tests to order and when, which medications to administer at which times, and which specific complications to check for. Everyone involved in the patient’s care has their own relevant checklist. From the moment of the patient’s hospital admission, the critical pathway predetermines when to take vital signs, when to get the patient out of bed, when to begin physical therapy, and when to provide standardized instructions to the patient before discharge. Every vital medical service is included, and all extraneous medical services are omitted.

A “case manager” monitors the care each patient receives under the critical pathway. Every deviation from the prescribed procedure is tabulated as a “variance.” Variances are tracked not to decide who to punish, but to identify areas of the process that need improvement. If too many instances of a particular variance are seen in a critical pathway, then either medical personnel need to be retrained on following the pathway appropriately, or the pathway itself should be changed to reflect more realistic expectations.

Critical pathways, in fact, proved to be extremely helpful in managing many medical conditions. But of course there were some drawbacks and limitations.

First, critical pathways are only useful for delivering medical services, like elective surgery, in which the process of care can be broken down into a predictable series of discrete, reproducible tasks that generate reproducible results. In other words, industrial management tools only work when the process of care is similar to the process of making widgets.

Critical pathways are almost worthless when you are dealing with medical illnesses in which neither the diagnostic procedures nor the treatments that may be employed can be predicted or, therefore, standardized. For instance, it has proven impossible to develop workable critical pathways to manage patients with congestive heart failure (CHF). Knowing only that a patient has been admitted to the hospital with CHF tells you nothing about whether that patient will require cardiac catheterization, a stent, bypass surgery, valve replacement, a pacemaker, an implantable defibrillator, a mechanical ventilator, a prolonged and complicated stay in the intensive care unit, or just a couple of diuretic tablets and overnight observation. No two patients with CHF are exactly alike; and there is no such thing as a standard patient. Unfortunately, most non-surgical medical services fall into this category.

Second, it turns out that when you are taking care of patients, the Axiom of Industry simply does not hold true. Standardization does not always improve outcomes and reduce cost. The reason for this is: Patients are not widgets. And while in theory everyone seems to agree that patients are not widgets, the implications of this fact appear to escape many of our public health experts.

If you’re a widget maker, deciding between two manufacturing processes is a matter of economics. Nobody expects you to consider the widget itself. The outcome by which you are judged has nothing to do with how many individual widgets get discarded during the manufacturing process or even the quality of the widgets that pass final inspection. Instead, it’s the bottom line: how much profit you make in relation to whatever level of quality you put into the widget. So the quality of the widget is not necessarily maximized, instead it’s optimized, tuned to the optimal quality/cost ratio as determined by the market forces of the day. This is why, for a widget maker, the axiom holds: standardization, by rooting out variability, reduces the cost of making the widget (at whatever quality level you choose). This automatically improves the outcome, because the outcome the manufacturer cares about is overall profit.

If instead of running a widget company you’re practicing medicine, the calculus is supposed to be different. You’re supposed to be more interested in how things turn out for individual patients than you are in the bottom line. So an expensive process that yields a better clinical outcome is one most people (patients, at least) would expect you to use, even though it only gets you a healthier patient and doesn’t help your bottom line. A process that increases patients’ mortality rate by five percent is one you should disregard, even if it is substantially cheaper than the alternative. The clinical outcomes experienced by patients — the measure of success you’re supposed to be concerned about — may move in the same direction as costs, or in the opposite direction. But because you’re dealing with patients instead of widgets, the Axiom of Industry doesn’t hold – and outcomes and costs do not always move in the same direction.

So the push to strictly apply managed care techniques to healthcare created a dilemma for doctors. Doctors – the widget-makers in this scheme – tried diligently to apply standardized procedures such as critical pathways to the care of their patients. But the more un-widget-like the medical services they were providing, the more often they were compelled to make variances to the prescribed standardized process, in order to best serve their individual patients.

Such variances are a legitimate and valued aspect of any industrial process. In the widget-making world, variances reveal that the process needs to be tweaked to make it more usable. Variances lead to further iterations and refinements of the process, and a steadily improving result. Exceptions are what allow these industrial processes to become self-correcting.

But in the messy world of patient care, the variances revealed instead that industry-like standardization only works for a minority of medical services. No amount of tweaking can standardize the management of complex patients with complex combinations of illnesses.

It did not take long for doctors to simply stop attempting to use critical pathways for un-widget-like medical services. They did this because they actually cared about what happened to the individual widgets in their charge.

Similarly, it did not take long for our public health experts to recognize the same problem. From their standpoint, however, the problem was not that patients are not widgets. The problem was that the doctors on the scene cared about the widgets. Further analysis revealed that the root of the problem was that classic managed care techniques like critical pathways were administered locally, and therefore the misguided loyalties of the doctors on the scene were allowed to rule the day.

The reason we don’t hear about managed care anymore is that such terminology refers back to those locally-administered, iterative, self-correcting, continuously improving industrial processes. And our public health experts have now realized that this model does not work, and must no longer be encouraged.

The solution to the widget-makers dilemma is to remove the dilemma. Since a dilemma requires one to choose between two options, any dilemma can be resolved by simply removing the choice. And this is what has now been accomplished.

There is no dilemma for physicians any more. Clinical decisions are now to be made centrally, by expert panels appointed by the government, through the mechanism of what is euphemistically called “guidelines.” Guidelines are sacrosanct rules that will determine precisely who is to get what, when and how. Doctors are now enjoined, both by law and by their new medical ethics, to follow those “guidelines” to the letter, without exception.

So instead of the locally-controlled, iterative, self-correcting quality improvement processes like critical pathways – the same kind of processes that have so significantly improved American automobiles over the past three decades – under Obamacare we are reverting to a central-directive-style of management, far more reminiscent of the old Soviet collective farms.

Why the Experts Insist They’re Right This Time

Complex systems controlled by expert-generated centralized directives have never worked and never will. The fact that experts always seem to espouse such systems – apparently under the theory that they are so much more clever, or have better information, or better systems, than those other experts who tried before and failed – is just one of the reasons we should always be afraid of experts.

And sure enough, the experts who are going to determine which medical care we in the herd will receive (and not receive) do indeed have a new and infallible system – a magic bullet – upon which to base those decisions. They call it “evidence-based medicine,” which certainly sounds like a useful thing. And further, the “evidence” featured in this new formulation, virtually by definition, must come from a specific kind of rigorous study called the randomized clinical trial, or RCT.

Bias in clinical trials has long been recognized as a problem. All clinical trials are inherently biased. A research study is biased from the moment it is conceived. And those who conceive of, plan, conduct, and analyze the clinical study have every advantage. (This, indeed, is the very reason why everyone is so indignant about the studies conducted by medical industry and their minions in the medical academy.) That advantage of bias is now, under law, defaulting to the government’s expert panels.

The formulation which our leaders would have us believe is that first, such government panels will be completely objective and unbiased, and second, even if they were biased, the fact that they are basing all their decisions on RCTs will eliminate any possibility of acting on that bias.

The idea that government-controlled expert panels will be unbiased, of course, is absurd. The reason these panels exist in the first place is to control healthcare costs. Since the main mechanism by which these experts will drive a reduction in spending on medical services is through the application of clinical trials – whose results the experts themselves will officially interpret – panelists obviously will be strongly biased toward interpreting those results in a way that will justify withholding expensive medical services.

And while they are busily spinning the results of RCTs, the same experts will be assuring us that RCTs provide a guarantee against bias. For, according to the Gospel of the RCT, the chief advantage of this sort of clinical trial is that it eliminates bias altogether, and produces a completely objective result. So, in order to do the right thing, one merely needs to follow the results of RCTs.

This gospel is incorrect. An RCT, like any clinical trial, is inherently biased from the very beginning.

Many clinical researchers believe in their hearts and souls that bias can be eliminated through the use of RCTs. In such trials, “like” groups of research subjects are divided randomly into two or more groups, and each group receives (for instance) a different therapy, whereupon differences in outcomes among the groups are attributed to the different therapies to which they were randomized. Indeed, the widespread belief that RCTs are the necessary and sufficient means to achieve “clinical truth” has become so deeply ingrained within the medical establishment that when anyone (such as your humble author) suggests otherwise, he immediately reveals himself to be a scientific Neanderthal.

The widespread belief in RCTs has become nearly a Cult in the medical establishment, whose creed can be reduced to three main tenets:

1) Data derived from randomized clinical trials represents Truth.
2) Data derived from non-randomized trials represents Falsity.
3) If you don’t believe this, you are a heathen.

Objective observers should find it at least a little ironic that an attempt to claim the scientific high ground has so obviously resulted in a new religion, replete with its own dogma.

The sad truth is that the results of RCTs are invariably dependent on the bias built into their design, and even if internally they are statistically legitimate their interpretation can usually be twisted to suit one’s preconceived notions – and for these reasons RCTs, like any clinical trial, can often send us down the wrong path.

Those who design RCTs (the smart ones, at least) know this. Like smart trial attorneys, they know the answer before they ever dare to ask the question. So they tailor their “question” in such a way as to yield the answer they want to get. Indeed, if a lawyer should end up asking a question in court that produces an unexpected answer, he or she is completely incompetent and ought to be sued for legal malpractice. In more cases than one might think, the same is true for those who design RCTs.

For instance, if you are an insurance company and want to limit the use of an expensive therapy, you design your RCT so that patients likely to respond favorably to the therapy are diluted within a broad population of enrolled patients, many of whom are less likely to respond favorably. This tactic will tend to make the average response of the whole population quite unimpressive. (In many instances the clinical characteristics of the likely responders and the likely non-responders will be reasonably apparent to the study designers.)

On the other hand, if you are a drug company that wants to encourage the use of your expensive new product, you design an RCT that preferentially enrolls the relatively small subset of patients who are most likely to respond favorably. Once your product has gained approval through the results of your RCT, you can then trust the marketplace (with a tweak from your direct-to-consumer advertisements) to “extrapolate” the results to broader categories of individuals.

So it is immediately obvious that RCTs do not eliminate statistical bias, as the dogma suggests. Rather, they simply offer an opportunity to control the statistical bias in your favor.

Sadly, it is often child’s play for interested parties (both government and private) to twist and spin RCTs to create the desired impression. The conceit of Obamacare – that industry-sponsored research is invariably biased, while government-sponsored (or government-interpreted) research is entirely objective, and therefore, that the only thing we need to assure accurate clinical research is to have it all controlled by the government – is dangerously wrong.

Since all clinical research entails bias, the appropriate way to approach any clinical problem would be to acknowledge that neither RCTs nor any other kind of clinical trial will reliably distinguish between Truth and Falsity, and that no (inevitably conflicted) group of experts should be given the exclusive authority to interpret clinical results. Then, given the possibly competing results from various studies – which often will not yield a firm “answer” – the individual doctor and individual patient can weigh the evidence and review list of risks and benefits most pertinent to that patient, and determine the optimal course of action given that patient’s particular circumstances and proclivities. Driving such a process, in fact, is what doctors are supposed to do.

But herd medicine does not allow for such individualized decisions, nor does it allow that there may be grey areas in clinical medicine, or that what’s right for one patient may not be right for another. Instead, it insists that RCTs must yield the Truth, that panels of very smart experts can discern that Truth, and that these panels can determine the one Right Answer that is applicable to the entire herd.

In the next few chapters I will demonstrate more specifically how expert-driven herd medicine can cause extreme harm to individuals, and to our society. I will finish this chapter by showing a recent example of how an RCT, even a straightforward one, can be twisted quite easily into a pretzel by biased interpreters.

Spining an RCT In Order To Shed Inconvenient Results

In 2010, the Archives of Internal Medicine published four (four!) articles assaulting the legitimacy and the importance of the JUPITER trial, a landmark clinical study published in 2008, which showed that certain apparently healthy people with normal cholesterol levels had markedly improved cardiovascular outcomes when taking a statin drug.

Superficially, at least, the JUPITER study appears to have been pretty straightforward. Nearly 18,000 men and women from 26 countries who had “normal” cholesterol levels but elevated C-reactive protein (CRP) levels were randomized to receive either the statin drug Crestor, or a placebo. CRP is a non-specific marker of inflammation, and an increased CRP blood level is thought to represent inflammation within the blood vessels, and is a known risk factor for heart attack and stroke. The study was stopped after a mean follow-up of little less than two years, when the study’s independent Data Safety Monitoring Board (DSMB) determined that it would be unethical to continue. For, at that point, individuals taking the statin had a 20% reduction in overall mortality, a dramatic reduction in heart attacks, a 50% reduction in stroke, and a 40% reduction in venous thrombosis and pulmonary embolism. All these findings were highly statistically significant.

This study is noteworthy because it was the first large randomized trial to show that taking a statin can markedly reduce the incidence of some very harmful cardiovascular outcomes in people who are considered to have “normal” cholesterol levels.*

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* Notably, typical LDL cholesterol levels among primitive hunting/gathering cultures is around 50 mg/dL, instead of the 100 – 120 mg/dL we consider to be normal. These primitive folks have an extremely low incidence of cardiovascular disease, so maybe humans’ optimal cholesterol level is much lower than we now think. On the other hand, the low risk of cardiovascular disease among hunters/gatherers may instead be related to the fact that many more of them than of us are consumed by various species of carnivores before they’re 30.
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To be sure, the JUPITER trial was far from perfect. Because of its design, it could not (and did not) tell us whether the beneficial outcome is specific to Crestor, or is a class effect of all statins (which seems very likely). It did not tell us whether reducing CRP levels is itself beneficial, or even whether using CRP as a screening tool is actually helpful. (The people enrolled in this trial tended to have several other risk factors, such as being overweight, having metabolic syndrome, and smoking, and it is not clear how much additional risk elevated CRP levels really added in this population.) And this trial did not tell us the risks of lifelong, or even very long-term, Crestor therapy.

But JUPITER did tell us something that is very useful to know, and with a very high degree of statistical surety: Giving Crestor to patients similar to the ones enrolled in this study can be expected to result in significantly and substantially improved cardiovascular outcomes, and in a relatively short period of time.

If medicine were practiced the way it ought to be – where the doctor takes the available evidence, as imperfect as it always is, and applies it to each of her individual patients – then the incompleteness of answers from the JUPITER trial would present no special problems. After all, doctors never have all the answers when they help patients make decisions. So, in this case the doctor would discuss the pros and cons of statin therapy – the risks, the potential benefits, and all the quite important unknowns – and place the decision in the perspective of what might be gained if the patient instead took pains to control their weight, exercise, diet, smoking, &c. At the end of the day, some patients would insist on avoiding drug therapy at all costs; others would insist on Crestor and nothing else; yet others would choose to try a much cheaper generic statin; and some would even opt (believe it or not) for a trial of lifestyle changes before deciding on statin therapy. In other words, there is an entire range of reasonable options given the limitations of our knowledge, as there often is in clinical medicine. As time goes by, more scientific evidence is often brought to bear and clinical decisions can become more informed. But whatever the state of the evidence, doctors and patients can generally get by without violating too severely any ethical or medical precepts that would cause objective and neutral observers to complain very much.

But this kind of individualized give-and-take between doctor and patient, in which the pros and cons are discussed in light of the patient’s own leanings, is no longer how doctors will practice medicine. Instead, they will practice herd medicine. Expert panels will decide whether people ought to take Crestor, or some other statin, or nothing – and that decision must apply to everybody.

And this makes the stakes very high when it comes to a clinical trial like JUPITER. For herd medicine does not permit a range of actions tailored to fit individual patients (consistent with the uncertainties inherent in the results of any clinical trial). Instead, under herd medicine the results of clinical trials generally cannot be permitted to remain imperfect or nuanced or subject to individual application, but must be resolved by a central panel of government-issue experts into a binary system – yes (do it) or no (don’t do it). In the case of JUPITER, the guidelines which some expert panel is going to have to produce will have to say whether or not to recommend Crestor to patients like the ones enrolled in the study, at a potential cost of several billion dollars a year.

It should be obvious that the answer which would be more pleasant to the ends of the Central Authority, and by a large margin, would be: No, don’t adopt the JUPITER results into clinical practice.

However, the expert panels which are called for by Obamacare have not been formulated yet, and we are still operating under the “old” rules. So, still subject to all the duress which is created by unfortunately-resolved clinical trials like this one, the FDA, somewhat reluctantly, approved the use of Crestor for JUPITER-like patients in late 2009. That approval, of course, is subject to review by the new expert panels, once they are actually in operation.

This, I submit for your consideration, is likely what instigated the almost violently anti-JUPITER issue of the Archives. It might even be suggested that the production of this extraordinary Archives indicates that we may be dealing here with a bunch of wannabe federally-sanctioned experts, auditioning for positions on the expert panels. What better way to get the Central Authority’s attention than to let them know that you are of the appropriate frame of mind to assiduously seek out scientific-sounding arguments to discount the straightforward and compelling, but fiscally unfortunate, results of a well-known clinical trial?

Of the four papers appearing in the Archives, three are more-or-less legitimate academic articles that make reasonable points, but do no harm to the main result of JUPITER. The fourth is a straightforward polemic, which has no place in a peer-reviewed medical journal, and whose very presence, I believe, strongly suggests that the editors of the Archives themselves may be auditioning for spots on an expert panel.

We can make short work of the three reasonably legitimate articles. One pointed out that JUPITER did not tease out the real importance of CRP levels, or whether lowering those levels is useful. This is true, but that fact does not touch the main conclusion of JUPITER. The second article was a meta-analysis which incorporated several other primary prevention trials using statins, and concluded that there is no overall benefit to statins in primary prevention patients. Aside from the usual problems inherent in meta-analyses, a) the JUPITER study looked at a specific sub-population of primary prevention patients unlike those addressed by these other studies, so whether these studies can be legitimately pooled is an open question, and b) since JUPITER is the first study to show a benefit in using statins for primary prevention, it is a foregone conclusion that if you assemble enough of the previous, negative studies and lump them together with JUPITER in a meta-analysis, you will be able to dilute the results of JUPITER sufficiently to achieve an overall negative result. Actually doing such a meta-analysis, then, is merely an exercise in math, not in revelation.

The third article criticized the JUPITER DSMB for stopping the trial earlier than originally planned. The DSMB, however, had no real choice in the matter – ethically or legally – given the striking statistical significance of the benefit seen with Crestor. When a patient signs an informed consent agreement to participate in a clinical trial, part of that “contract,” a part required by law, is a statement to the effect that if information comes to light during the course of the study that might impact a patient’s willingness to continue participating, that information must be made available. The fact that the Crestor branch of the study was found to have markedly and significantly improved survival, fewer strokes and heart attacks, &c., than the placebo branch, clearly constitutes such information. Indeed, it is the job of the DSMB to monitor the study for this kind of information, and to stop the study whenever it becomes certain that continuing it would expose study participants to unreasonable risks. This is why independent DSMBs exist in the first place – to protect the rights and welfare of the research subjects under the fiduciary agreement that comprises informed consent. Stopping the study when they did was not “premature;” continuing the study would have been illegitimate.

This same argument – that RCTs should never be stopped prior to the original stopping point – has been raised in the intervening years by several other experts. It is a viewpoint one perhaps ought to expect from purveyors of herd medicine. The DSMB, after all, is an artifact from a time when the patients agreeing to be enrolled in an RCT were considered to be individuals, who of their own free will volunteered to participate in a clinical trial where some aspect of their therapy would be determined by chance, and whose interests, accordingly, ought to be protected. The notion that a trial ought to be driven to its pre-set conclusion, even after it is shown that doing so will cause predictable and measurable harm to individuals in one arm or another of the trial, derives naturally from a herd medicine paradigm. Such a notion ought to give anyone pause before agreeing to participate in an RCT today.

The fourth article is more striking (and more fun) than the other three. Interestingly, it was categorized by the Archives as an “Original Investigation,” despite the fact that it describes no investigation of any kind whatsoever – original or derivative. It merely revisits the data from JUPITER (in a spectacularly biased manner), and offers a spate of ad hominem attacks, alleging bias to the point of corruption, without any supporting evidence, against JUPITER’s sponsor, its investigators, and most astoundingly, the chair of the DSMB (who is a well known and highly respected figure, especially known and revered for his complete objectivity and lack of bias). If such an article has any place at all in a peer-reviewed medical journal – which I doubt – it ought to be clearly labeled as an opinion piece, and not as a piece of original research. Whatever it may be, it’s not that.

But the most delicious aspect of this fourth article is that two of its authors, including its lead author, are members of a fringe medical group known as The International Network of Cholesterol Skeptics (THINCS), whose stated mission is to “oppose” the notion that high cholesterol and animal fat play a role in cardiovascular disease. Members of THINCS also take an extraordinarily strong position opposing statins for any clinical use whatsoever. (One might actually assume that, since JUPITER shows that cardiovascular outcomes can be improved by statins in people with normal cholesterol levels, the THINCS would embrace the study as evidence that perhaps cholesterol is not as important as it’s cracked up to be. But apparently, this argument is completely negated by the fact that statins were the vehicle for making it. Many in the anti-statin crowd would object to statins even if they were proven to cure heart disease, cancer, baldness, and obesity AND produced fine and durable erections upon demand.)

The best part of all this is that the astounding anti-cholesterol, anti-statin bias of the authors was not disclosed in their article – whose main thrust, again, was to criticize the disclosed biases of the JUPITER investigators.

The venerable Pharmalot blog noted this irony, and contacted Dr. Rita Redberg (editor of the Archives) and Michel de Lorgeril (THINCS-master and prime author of the fourth article) to ask them why the association with THINCS was not disclosed.

Redberg: “I’m not clear this is an undisclosed conflict. The policy mentions a personal relationship that could influence one’s work. I think that could be a big stretch. My initial impression is the group has an intellectual message, but doesn’t fit as a personal relationship that could effect the authors’ work.”

de Lorgeril: “[While it is] very important to disclose financial conflicts of interest that can influence our way of working and thinking about cholesterol and statins, there is so far no obligation to provide a CV each time we publish any thing…May I underline the fact that being a member of THINCS – not a group of terrorists, mainly a club of very kind retired scientists with whom I have interesting and open discussion – is not a conflict of interest?”

I may be old fashioned, but I think that being a member of an “out there” group like THINCS, which appears to advance selected and distorted data on its own website aimed at furthering its stated mission of “opposing” (not investigating or questioning) the cholesterol hypothesis and the use of statins, might make one prone to a bit of bias when writing a broadside critiquing a study like JUPITER, and loudly criticizing anyone associated with that study for their bias.

The irony here is amazing. The lack of embarassment is astounding.

This sort of bias (demonstrably rooted in a willingness to select/ignore/distort data in order to make a preconceived point) is likely to be as strong as any that might accompany, for instance, receiving a stipend from a statin company for participating in clinical research. Membership in THINCS may not preclude one from writing such an article, but I think the association at least ought to be disclosed, just as financial relationships must be disclosed.

I have a hard time explaining how this can happen with a prestigious medical journal like the Archives. But like Sherlock Holmes says, when you have eliminated the impossible (such as, the idea that this article deserved to be published in its current form), whatever remains, however improbable, must be the truth.

And this is why I am forced to suggest that several of the authors appearing in that issue of the Archives of Internal Medicine, along with its editors, may be in the mode of ingratiating themselves to the sundry officials and czars within the govenment who will be assembling the expert medical panels which will be making the momentous decisions that will determine the flow of hundreds of billions of dollars, and (forgive me) of life and death.

Admittedly the issue of the Archives I have been discussing does not accurately reflect the general tenor of criticism the JUPITER trial has engendered in the academic community, which has been far calmer and less polemical. The fact is that the implications of this trial, when straightforwardly interpreted, are very disturbing to payers, both private insurers and the government. So in the years since this study was published there has been a general effort to diminish its results, from several fronts, that, taken together, should give future expert panels plenty of legitimate-sounding resources with which to deny its application to the herd.

This larger group of critics of the JUPITER trial all come from the legitimate medical establishment, and are proponents of using RCTs to make medical decisions. They claim to be willing to follow the data from RCTs to wherever they may lead.

For these critics, it seems pretty clear that the chief concern regarding JUPITER is its cost implications. That is, these people feel strongly that it would simply be too expensive to follow the results of the JUPITER trial to their logical conclusion. This, indeed, would be a very reasonable position to take – as long as their argument went something like this: “Yes, the JUPITER trial shows that many lives would be saved if people like those enrolled in the study would take Crestor, but it’s just too expensive to buy Crestor for all these people.”

But this sounds like rationing, and Americans don’t ration. So instead critics, even those pure thinkers in the academy, have tried to attack the results of JUPITER, arguing that the results of the study actually do not support the use of statins in these patients.

Unfortunately, turning aside the results of a statistically definitive RCT can be a challenge. In fact, the need to discount the results of JUPITER leaves critics little choice but to engage in statistical legerdemain. There are several useful techniques they can employ to this end.

Many of the arguments that have been ginned up in this effort have derived not from data published in the JUPITER trial itself, but instead from statements made in an editorial written by Dr. Mark A. Hlatky, and published in the same issue of the New England Journal of Medicine in which the JUPITER study itself appeared.

Most of Dr. Hlatky’s editorial is measured and reasonable. But along the way – either inadvertently or slyly – he threw in a key summary sentence that has been greedily grasped by those who would discount the JUPITER results, to wit: “The proportion of participants with hard cardiac events in JUPITER was reduced from 1.8% (157 of 8901 subjects) in the placebo group to 0.9% (83 of the 8901 subjects) in the rosuvastatin [Crestor] group; thus, 120 participants were treated for 1.9 years to prevent one event.”

This statement, at least taken at its face value as a stand-alone analysis, is statistically naive, and fundamentally wrong.

In a long-term clinical study in which the endpoints are events that can occur at any time (such as heart attack, stroke or death), then the probability that an enrolled patient will reach an endpoint during the trial increases the longer he/she has been enrolled. But in virtually all clinical trials, the length of time different people are enrolled varies greatly. This is because it often takes years to enroll people in clinical trials, so that when the trial ends, some will have been in the trial for many years, others for only a little while. This means that the risk exposure of each research subject is different, and is proportional to the total time they were enrolled. Not uncommonly, the enrollment process is not smooth – there are periods of more rapid enrollment, and periods of slower enrollment – so if all you do is average the enrollment time (as was done by Hlatky – 1.9 years) you are likely to get skewed results. So it is simply not statistically legitimate to do so.

There is a legitimate, well-known and universally accepted method for analyzing these kinds of longitudinal outcome statistics, and it’s called the Kaplan-Meier method. And indeed, the authors of the JUPITER trial presented in their paper a complete Kaplan-Meier analysis of their data, and the results look quite a bit different from Hlatky’s summary statement. The Kaplan-Meier analysis reveals that the risk of heart attack, stroke, and death all increase steadily through at least four years, so that at four years after enrollment the risk of reaching one of the “cardiovascular event” endpoints was about 8% (not 1.8%). Further, the Kaplan-Meier analysis shows that the protection imparted by Crestor persists through at least four years, and that indeed the magnitude of protection (i.e., the difference in outcomes between the treated group and the placebo group) increases throughout that entire duration. So, four years after enrollment in the study, the placebo group had roughly an 8% event rate, compared to roughly a 3% event rate for the Crestor group – an absolute difference of about 5% (not 0.9%). This is a far greater benefit than is suggested by Hlatky’s shorthand summary.

Suffice to say, then, that Hlatky’s summary statement apparently ignores the appropriately analyzed data which is clearly presented in the JUPITER paper itself, and which documents that the clinical benefit of Crestor was substantially more impressive than his widely-quoted summary statement suggests.

But as misleading as this summary statement may be, let us accept it at face value for a moment just for the sake of discussion, since that’s the data the JUPITER critics have chosen to latch on to.

Taking these numbers, the critics make the following argument: While the relative reduction in “hard cardiac events” is 50% (1.8 to 0.9), the absolute reduction is only 0.9%, which, anyone would agree, is a pretty small number. So, they conclude, the actual benefit imparted by Crestor is actually quite small.

That’s a very interesting argument. Let’s look at it in a couple of ways.

So we’ve got a population of patients whose risk of heart attack, stroke, bypass surgery/stenting, or death is about 2% after about two years, and by giving them a pill we can reduce that risk to about 1%, and we’re arguing that the absolute drop of 1% is not very much to crow about. Well, OK. But what if we found a pill that reduced their risk to zero at two years? That is, it completely wiped out the risk of cardiovascular catastrophes altogether. Would that be a good thing? Or would we say, “It’s just a 2% drop, really not much greater than the 1% drop we had with Crestor, so it’s no big deal?” I think not. I suppose we would think that totally eliminating all cardiovascular risk would be a very big deal indeed.

When you’re starting at a 2% risk, then any drop in risk is going to be an “absolutely” small number. And if we’re not going to pursue improvements in outcome of such a small magnitude, then why the heck are we worrying about preventative medicine in the first place? Once you get past the big things (drain the swamps, don’t drink the water downhill from the outhouse, &c.) then all preventative medicine tends to consist of small, incremental improvements in outcome. Popular pronouncements to the contrary notwithstanding, preventative medicine is largely the art of spending a lot of money for this magnitude of incremental improvement. If we Americans decide we shouldn’t do this anymore, then I would find it unfortunate but understandable. But it hardly seems reasonable to arbitrarily focus on this one, particular improvement in preventative cardiology, and (within a healthcare system that insists it is not rationing care) pronounce that this is the one we’re not paying for.

Another way of looking at this “the benefit is too small” argument is by considering that 7.4 million Americans fit the entrance criteria for JUPITER. By giving all these people a statin, we would be preventing about 66,600 major cardiovascular events over a two year period. If you’re going to say that 1% is a small number, I will counter by arguing that 66,600 is a big number. So do statins offer a substantial benefit or not? It depends on whether you choose to focus arbitrarily on the 1% or the 66,600.

(I understand that you may not be focusing at this moment on the 66,600 cardiovascular catastrophes that could be prevented, but on the 7.4 million people who will be taking a drug that costs $120 per month. But we’re not talking about cost yet, we’re only talking about whether the drug does some good. If we decide it does, then we’ll need to link that “good” to a procedure that measures whether the “good” is worth the money we would need to spend to achieve it. The critics of JUPITER try to avoid talking about cost – since that would admit they’re rationing – by insisting that there’s just not enough “good” to bother with. I am simply pointing out that such an argument – that preventing 66,600 very bad outcomes is not enough to bother with – is on its face absurd.)

Another argument invoked by critics is based on the “number needed to treat” (NNT) analysis. Again they rely on Hlatky’s unfortunate summary of the data: “120 participants were treated for 1.9 years to prevent one event.” This number – which the critics insist is just too high – is misleading for the reasons already discussed. The real NNT, based on more legitimate statistical analysis, is plainly laid out in the JUPITER paper itself. It turns out that the longer patients in this trial were treated with Crestor, the lower the NNT became. So: At two years, the NNT was 95; at four years, it was 31; and at five years, it was projected to be only 25. Whether you think it is reasonable to treat 25 people with a pill for five years to prevent one of them from having a heart attack, stroke, or death is, I suppose, a matter of opinion. But based on NNT analyses for many widely-accepted therapies in medicine today, it looks pretty good.

All these arguments, of course, are merely distractions. The fact is that JUPITER showed a pretty striking reduction in some very nasty cardiovascular events over s pretty brief period of time, and the only real reason there’s any controversy at all is because of the cost of Crestor.

That cost is what makes us want to withhold Crestor, even though it is imparting at least some (and, I am arguing, quite a bit of) clinical benefit. In other words, the high cost makes us want to ration Crestor. The fact that we can only ration covertly, instead of openly, is what makes us want to bastardize the science and do a Kabuki dance with the statistics.

If we worked under a Method Three healthcare system, where the strict limits on public spending were determined openly, then we could do an objective, full-bore cost-benefit analysis on the use of Crestor in JUPITER-like patients, using legitimate and not ginned-up statistical analysis, and taking into account not only the cost of the drug, but also the cost that would be incurred by failing to stop preventable heart attacks, strokes, &c., and then determining where the overall cost-benefit result fell within our coverage criteria. If it met the criteria we would cover it, if not, not. This decision would not be arbitrary. It would be a fully transparent process, so that if the sponsor did not like the results, they would try diligently to find a way to reduce the cost of Crestor (I think they would succeed) to a value that would be compatible with their staying in business. (And for the first time, the price of medical products would be determined by a Laffer-like curve, where a price that was too high – like taxes that are too high – would reduce revenue, instead of increase revenue. Companies, being fairly rational, would ratchet their prices down to the optimal price point.)

But since we insist on doing our rationing covertly, I am sorry to say that we’re destined to keep making spurious arguments, and using dumbed-down statistical analysis to back them up. The JUPITER trial, while it is imperfect and while it does not answer every question, really is pretty straightforward. That we get so wrapped around the axle trying to fold such clinical trials into our covert rationing paradigm is simply another demonstration of the fact that covert rationing corrupts everything it touches.

The fact that so many respected academics are making such spurious statistical arguments is disconcerting and discouraging. Among other things, it means that the Central Authority will have many, many fully-domesticated experts to choose from when they assemble their all-powerful expert panels.

Summary

Herd medicine will follow naturally from any centrally-controlled Progressive healthcare system. Unless you are lucky enough to be included in the expert class, or are a part of the government leadership that controls the expert class, this is not a good thing.

Medical services that give substantial benefit to a minority of people will not be offered to any people, since the “herd effect” will likely be below an arbitrary cut-off value. Medical services that do make the cut will be prescribed for everybody, even though (since herd medicine is tuned to the average response across the population), something like half the population will respond less favorably than average. Herd medicine will stifle medical progress. And herd medicine will entice medical experts, who need to curry the favor of Progressive leaders in order to be recognized as legitimate experts, to abuse the science and the statistics of clinical trials.

It is important to note that while those of us who reside within the herd will find these features of herd medicine problematic, for our Progressive leaders herd medicine – which offers the centralized control they find absolutely necessary – is an unalloyed boon.

This is Chapter 5 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.

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Chapter 5 – A Practical Theory Of The Progressive Program

My goal in Part I of this book has been to describe the sorry state of the American healthcare system pre-Obamacare. Before moving on to Part II – which will attempt to show why “fixing” the problem by instituting Progressive healthcare reforms is exactly the wrong thing to do – it occurs to me that I ought to explain exactly what I mean by “Progressive.”

What I have done so far in this regard – which has consisted of offering unflattering innuendoes, casting negative aspersions, remarking snidely, and quoting from Ayn Rand (who I think was brilliant in characterizing the diagnosis, but whose prescription – unfettered and godless self-interest – I find a little disturbing) – has not exactly constituted an exercise in probity and precision. In this final chapter of Part I it is my intention to remedy this shortcoming.

To really understand where our healthcare system is headed, and for that matter where our society is headed, we need to understand Progressives and the Progressive Program.

I have personally found this understanding hard to come by. This is because Progressives, and especially American Progressives, have always been a bit enigmatic about their real goals. In my view their behavior tends to be persistently, almost defiantly counterproductive to the rights Americans traditionally hold dear, and which the Progressives themselves insist they revere – in particular, our inalienable rights to life, liberty and the pursuit of happiness.

Even a superficial analysis of the words and deeds of Progressives should reveal that, their protests to the contrary notwithstanding, they never really bought into the “inalienable” thing. It is quite apparent, to anyone who cares to look, that for Progressives such “natural rights” can and must be abridged whenever it is necessary to achieve some higher goal.

Since the behavior of American Progressives is so often inconsistent with the values they (most of them, at least) insist they love as well as any American, I concluded long ago that they must either be prevaricators or self-deluded when it comes to telling us what they are really up to. Either way, if we want to know what they really think, and what their agenda really is, we’ll have to figure it out for ourselves.

And perhaps we’d better do just that, since it is looking a lot like the Progressives are going to be running things around here for a while.

I am not a political scientist. But I am a scientist. And for a scientist, one useful way to learn about any kind of system is first to make as many observations as you can about that system, then devise a theory to fully explain those observations, and then apply that theory to attempt to predict future behaviors of the system. As you observe how your theory is working, you can then go back as needed and readjust it to comport with your new observations. Repeat until done.

When you get to the point where subsequent, otherwise-difficult-to-explain behaviors have become predictable, your theory is reasonably likely to be in the ball park.

And so, I am going to present a theory of Progressivism. It is a theory that I have found useful in explaining many of the otherwise confounding and enigmatic behaviors which Progressives habitually display. I am not claiming that this theory is absolutely correct, merely that it is useful in practice. Since it is a theory whose value you can assess objectively with your own observations, its practical value should not depend on my own character, morals, intelligence, or psychological status, all of which have been impugned by readers of my blog in the way of proving that my theory cannot have any merit. (Simple observation suggests that Progressives generally allow only three possibilities when somebody disagrees with them – you can be crazy, stupid or evil. Their prescribed remedy – therapy, education, or elimination – depends on which of these possibilities they finally settle upon. My theory, obviously, will have to explain this behavior, too.)

You may not like this theory. A lot of people don’t. But the thing about the scientific application of theories is that if you are going to make any, well, progress, you cannot simply write off or ignore theories whose implications you do not happen to like. Whichever theory is currently the best at explaining the known facts necessarily takes precedence, until such time as you can devise a new or adjusted theory that explains those facts even better.

I would welcome hearing about such a theory. In the meantime, here’s mine.

A Hopelessly Abbreviated History Of Progressivism

When I began my study of Progressives, I honestly did not know where to begin. So, like Descartes before me, I decided to proceed from the simplest and most irreducible of truths. Namely, that Progressives are really, really smart. We know this because all the best professors in all the best Ivy League schools are Progressives.

From this simple truth we can deduce that, whatever it is that Progressives are actually up to, it must have its roots in the writings of The Philosopher.

And sure enough, it was not at all difficult to discover the roots of Progressivism within the teachings of Aristotle. Aristotle tells us that man is innately a political animal, an animal with an inherent propensity to gather into increasingly complex communities. The essence of man, according to Aristotle, is society.

The formation of complex societies is what defines mankind; it is what differentiates man from the rest of the animal kingdom. Hence, because man is defined by society, society is inherently on a higher plane of importance than the individual. Individuals are entirely beholden to and dependent upon and subservient to the society to which they belong. Indeed, they are defined as individuals by their place and status within that society. Without society, a man is just an ape with better thumbs.

And so the precedence of the collective over the individual is not something we can simply choose to accept or reject; it is the very essence of mankind. It is nature. It is just the way it is.

Aristotle, as we can see, is a great friend to the Progressives.

The general idea that mankind is essentially a creature of society, and that the worth of the individual is defined by his/her worth to their society, is thus a very old idea, and in fact has been the normal way of looking at the relationship between individuals and society throughout most of history.

This really started to change just a few hundred years ago, when humanists began to cautiously explore the radical notion that individuals (rather than the collective) constitute the fundamental unit of humanity. The new humanist heresy – which declared the innate and irreducible worth of the individual and began to celebrate individual “autonomy” – came to be called “liberalism.” Classical liberalism stressed individual freedom of thought and action, the right of private property, individual responsibility, free markets, and the limited power of the state. Classical liberalism reached its zenith a mere two and a half centuries after its painful birth, with the Declaration of Independence and the Constitution of the United States. The formation of a new nation whose government was explicitly established on the grounds of classical liberalism is what I’ve been calling the Great American Experiment.

The Great American Experiment, so far at least, appears to be a once-in-a-species event. So if we’re about to abandon it, I would caution that perhaps we should first really think about it for a while.

In any case, even in America the collective countercurrent never really went away. And it never will, if only due to its extraordinarily deep roots in the history of men. And so, after only a century or so of relatively unfettered capitalism (the natural economic system of classic liberalism), during which the industrial revolution had been whipped to new heights, leading to unimagined progress and economic growth but also, alarmingly, to the creation of a large new underclass of hopelessly poor and horribly oppressed urban dwellers, collectivist thinkers were stirred to new action.

In some countries the “action” consisted of violent revolutions and all the bad stuff that typically follows such things. In the United States, the collectivist movement followed a much more prudent, much more practical, much more gradualistic approach.

Taking its cue from the industrial revolution, which by radically transforming the modern world had graphically introduced the idea of “progress,” and fascinated by the ideas of Darwin (which suggested not only that a system could be steadily and unrelentingly directed toward some state of “perfection,” but also that the very nature of things seemed to dictate that it should be so), the new collectivist movement at the turn of the 20th century adopted the name “Progressive.” To Progressives, classical liberalism has always been an aberration. Despite what America’s founding documents might say, society takes precedence over the individual. It takes this precedence by way of the very essence of mankind, as was taught by The Philosopher, and so it cannot be otherwise.

(Within a couple of decades, “Progressives” had gotten such a bad reputation that they brazenly began referring to themselves as “liberals,” usurping the terminology from a philosophy that was nearly its opposite, as if to convince the public that they actually held to those foundational American precepts of individual liberty, limited government, &c. But true to form, by 2008 they had pretty much trashed the name “liberal” as well, at which time Hillary Clinton famously declined to call herself a liberal any longer, and insisted instead that she was a “Teddy Roosevelt Progressive.” It is therefore in deference to Ms. Clinton’s explicit instructions that I am using that original terminology in this book.)

The Progressives, following unrelentingly their steady, Darwin-inspired evolutionary-not-revolutionary approach, have made astounding strides. Today they are on the verge of rendering their Program irreversible. And taking over the healthcare system will likely lead them to the final victory for which they have striven, so patiently and for so long.

The Progressive Program

Progressivism is a political movement whose premise is that the society of men can be perfected, and therefore it is the highest duty of any “good” society to constantly strive toward that achievable state of perfection. And so the Progressive Program – the thing that makes Progressives progressive – is to develop the perfect society. This program is not optional; it is dictated by the nature of mankind. It is therefore “right,” and objecting to it is therefore “wrong.”

The perfect society has three fundamental requirements. First, it must meet all the basic needs of the individuals within that society (such as food, clothing, shelter, sanitation, and health), without which individuals will always be tempted to engage in the counterproductive behavior of striving for things. Second, the social and economic benefits of society must be fairly distributed among all people. Therefore, there must be social justice – there must be no big winners or big losers. Big winners are an especial problem, because the presence of big winners just encourages greed and self-aggrandizement on the part of others, and will discourage citizens from dedicating themselves to the good of the whole. Third, once perfection is finally achieved, the social order must be of such a nature that it can persist, theoretically forever, without fundamental change. Indeed, the very notion of perfection implies that any change, of any type, is bad, since it will necessarily constitute a movement away from perfection. (This means, of course, that once the Progressives reach their goal, they will need to change their name. Of necessity they will become Conservatives.)

The perfect society therefore requires that people be granted “rights” to things – food, clothing, shelter, healthcare, &c. These rights obviously do not come from any Creator – so where do they come from? They can only come from a Central Authority – from the sovereign entity within a society that has the ultimate authority (backed by the legal use of violence or the threat thereof) to distribute the fruits of the society in such a manner that all those rights can be realized.

Progressives love to grant new rights to everyone, because each time they do, the Central Authority accrues that much more power over the behavior and the property of individuals.

The perfect society demands social or redistributive justice in all areas of social and economic endeavor, even in areas that have not yet been defined as a formal “right.” Once again, only a strong Central Authority can determine what is fair or not fair, and can have the power to affect the appropriate redistributions it determines are necessary to achieve such fairness. The aforementioned creation of “rights,” of course, will guarantee that such a powerful Central Authority will have been established, so that social justice can progress steadily forward.

The perfect society requires complete stability. This would include (at a minimum) a stable population size, the preservation of natural resources and the earth’s environment (indeed, when one hears the word “sustainability,” one is usually listening to Progressive gospel), the careful management of the economy, and the careful control – if not suppression – of unplanned innovations.

This latter refers both to material (or scientific) innovations, and innovations of thought, either of which will always threaten hard-won societal stability.

Achieving the perfect society being the paramount work of mankind, any method which may help in achieving this perfection is to be embraced; none discounted out of hand. The only considerations one must make in choosing methods of action are: Is this method practicable? And: Is this method more likely to be successful, or counterproductive?

These two questions fully define Progressive ethics.

And finally, the Central Authority exists purely to grant essential rights to the people, to determine what is fair and then act to effect that fairness, and to establish the executive structures needed to achieve and maintain societal stability and sustainability. Therefore, by definition, as long as its actions are directed in these ways, it is an inherently ethical entity and must be regarded as such; and further, resistance to it is (equally inherently) unethical.

That’s it. That’s my theory of the Progressive Program. If you object to it, then, despite whatever personal shortcomings, sins, and wants you may perceive in your humble author, you are obligated (by all that is righteous and good) to postulate your own theory of Progressivism that explains, at least as well as my theory does, all of the following phenomena:

Rule By Experts

Despite its lip service to the contrary, Progressivism is not egalitarian. It simply cannot be.

For, while Progressivism is not by definition a system of rule by the elite, in practical terms it can only end up this way. Progressive leaders (themselves being quite elite) are never slow to perceive this truth.

It works like this: The duty of mankind is to strive for the perfect society. The chief tool by which mankind is to achieve this program is man’s intellect and logic. It is axiomatic that only a minority of people will have the intellect and logic necessary to direct the Program of mankind.

Therefore, Progressivism ultimately relies on an elite corps of individuals – formally called “experts” – to guide our progress toward the perfect society. The perfect society will not just happen, it must be engineered by those who are expert enough to know what to do, and who are gifted enough to lead.

Those leading experts, the rare individuals without whom we will never achieve our state of perfection, are to be carefully nurtured and valued by society. Because their work is so critical to the essential Program, the elite must be removed from worry over the mundane necessities of life. That is, providing the leadership class with certain luxuries and privileges, and even freedom from having to follow all the rules that apply to the masses, is therefore not hypocrisy, but is an essential good. It redounds to the benefit of the Program, and therefore, to everyone.

This is why Progressive leaders habitually accept special privileges and perquisites that would make the King of Siam blush, and they do so with an air of matter-of-factness and entitlement that is impressive to behold.

The Duty of We the People

Just as it is the sacred duty of those who have been blessed with the intellectual tools to lead us toward the Promised Land, it is no less the sacred duty of the rest of us – we in the unwashed masses – to do whatever it is that the experts determine is best. The determinations and directives which the experts hand down may apply to all people, or they may be specifically directed toward you or me (which indeed would be a very great honor for us, would it not?) Either way, it is our duty to comply with all central directives, for the greater good of the whole.

This explains why Progressives express such indignant wrath over the Tea Party. Tea Party enthusiasts insist that their own individual autonomy must remain paramount, and utterly deny that they have any duty to comply with the Progressive Program. This attitude, of course, makes members of the Tea Party stupid, crazy or evil. And, because the Progressive-in-Chief happens to be an African American who is acting within the prescribed range of behaviors for African Americans, it also makes them racist. (More on this latter point shortly.)

Progressives vs. progressives

Progressives (capital P), as I use the term, are the thought leaders of Progressivism. They are the experts, the leadership class. They are the political leaders, the academics, the authors, the bureaucats, and the pundits and spokespersons who set the agenda, make the decisions, form and transmit the message, and pass the judgments that make the Progressive engine run. They are the ones who know the way to the perfect society, and are driving us to it.

On the other hand, progressives (the “small-p-progressive,” the rank and file, one-of-us progressives who spend their lives toiling away within the general population), who form the large majority of American progressives, are basically just nice people. For the most part progressives honestly believe that their political philosophy is the right philosophy, the fairest philosophy, and innately the kindest and most humane political philosophy there can be. They are not trying to drive society toward perfection as much as they are merely aiming for more fairness in the distribution of the good things that come from being in a society in the first place.

Small-p-progressives do indeed tend to look at non-Progressives, and especially Conservatives, as being driven chiefly by vice – usually selfishness and greed – and so are subject to being induced to states of great indignation and anger (by Progressives) against specific non-Progressives, and can often be mobilized to action against same.

So, within the great unwashed masses, progressives are seen by Progressives as the ones who bathe at least weekly.

The Fundamental Flaw Of Progressivism

The fundamental flaw of Progressivism is the same as the fundamental flaw of all collectivist political systems. Namely, Progressivism ultimately relies on all members of society to subsume their own individual needs to the needs of the collective. That is, the Progressive Program requires a fundamental change in human nature. And alas! This change will never be forthcoming.

All ideal political and economic systems – including capitalism – eventually founder on the shoals of human nature if certain adjustments are not made. However, collectivist systems are especially vulnerable to human nature. Unlike capitalism (which incorporates, utilizes and makes the best of the individual’s innate self-centered nature), collectivist systems require the complete suppression of man’s natural impulses (again, unless you are lucky enough to be amongst the leadership class). So collectivist systems are rapidly and deeply challenged by human nature. It is their fundamental flaw.

This fundamental flaw will almost always lead to great frustration on the part of the leadership of any collectivist system, dooms their attempts at societal perfection, and finally results in tyranny or anarchy. This is why, while collectivist systems often sound quite attractive to the inexperienced youth or their unaware elders, collectivism always tends to end badly.

So, despite their frequent hymns of praise to the worthiness of the common man, Progressives invariably develop an underlying contempt toward the unwashed masses. It is not difficult to spot this contempt if you are alert to it.

Managing the Unwashed Masses

Instead of surrendering to the inevitabilities of human nature, Progressives will instead try to “manage” the unwashed masses.

Now, for your typical American progressive, getting people to go along with the Progressive Program will be a simple matter of education. The Progressive Program is so obviously Right, and anything else so obviously Wrong, that anyone can see it with a minimum of instruction. These progressives believe this because it is how they themselves were won over.

But the Progressives – the elite class of leaders, who have probably been to Harvard – understand that education (i.e., indoctrinating the public to the great benefits of the Progressive agenda), only goes so far. It does indeed get you a substantial number of believers (probably 20 – 25% of the population), but it still leaves you with a very large proportion of the people who will only go along to the extent that they themselves benefit.

And so Progressives attempt to control the unwashed masses by means of pacification (i.e., attempting to meet all their basic needs, so as to eliminate their impulse to strive). This helps quite a bit – in fact, it is one of the main strategies of the Progressives for controlling the people.

Unfortunately, even this does not work in a substantial number of people. Some people, no matter what kind of indoctrination you provide for them, or what benefits and entitlements you may offer them, will simply refuse to place the needs of the collective above their own.

In other collectivist systems we have seen around the world, the utter frustration that develops on the part of political leaders because of this innate human recalcitrance seems nearly inevitably to lead to coercion, intimidation, peer-pressure, and, ultimately, violence*. When the expediency of violence is finally reached, you inevitably end up with the tyranny or anarchy I mentioned earlier.

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* According to R.J. Rummel in his book Death by Government, during the 20th century the world’s governments killed four times as many of their own people, on purpose, as were killed in all wars combined.
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In the United States, while the frustration of our Progressive leaders with us folks is often palpable, and while their growing contempt for us occasionally breaks through the surface, so far wholescale violence has been avoided. I think this is at least partially because of a unique invention of American Progressives – Diversity.

The Importance of Diversity

“Diversity” was once merely a pleasant feature of some population or group, a nice-to-have, a quality that implied a certain open-mindedness, an acceptance of different kinds of people, or thoughts, or music preferences. In recent years, however, Diversity has been transformed into the Uber-Virtue, the highest virtue of all, the virtue from which all the other subsidiary (formerly cardinal) virtues must necessarily spring. Today, when planning any new endeavor, no matter of what type or for what purpose, your chief and overarching consideration must be – can only be – to achieve Diversity.

How did it get to be this way?

It all comes from the Progressive Program, which, again, is to create the perfect society. The Progressive elite know just how to do this, of course, but individuals within every population throughout human history have insisted upon acting in their own self-interest, which is counterproductive to the collective goal. In many places which have made similar efforts to perfect human societies, such individual recalcitrance has been dealt with by means of concentration camps and pogroms and the like.

“Diversity” is a much kinder and very much gentler approach to curing the problem of individualism. With a critically important goal like that, Diversity has naturally assumed a primary place in our society.

Specifically, the doctrine of Diversity defines the range of permissible behaviors and thoughts – Right Actions and Right Thoughts – for a given group of people within a society. Diversity informs you of how to be a legitimate and accepted member of your group.

The numerous celebrations of Diversity we see all around us invariably turn out to be strategies to reinforce those allowable ranges of thought and behavior. In this way, members of a particular group can be individually celebrated as embodying the characteristics assigned to the group. Conversely, those who begin behaving and thinking outside the allowable range can be quickly identified and dealt with, either through correction (which brings them back into the group), or through vilification (which completely marginalizes and devalues them within society). So, for instance, Al Sharpton and Jesse Jackson are celebrated individuals, whose accomplishments nicely reflect their assigned group identities. In contrast, Clarence Thomas and Thomas Sowell are not celebrated by Progressives, and indeed are castigated as abominations, because their individual accomplishments do not reflect their assigned group identities.

This concept, I believe, also helps us to understand what Progressives mean by “racism.” Racism is when you criticize a person, for any reason, who is acting entirely within the expected range of behaviors of their assigned group. On the other hand, it is not racism – and indeed, it is strongly encouraged – to criticize a person who is acting outside of his/her allowable range of behaviors. So criticizing Louis Farrakahn for calling Jews devils is racist. Saying anything nasty about Thomas Sowell, for any reason whatsoever, is perfectly acceptable.

Similarly, the concept of Diversity helps us to understand why it is laudable for Progressive commentators to say extraordinarily vile things about Ms. Palin and Ms. Bachman (and their children); but it is the height of sexism (sexism being a mortal sin) for Conservative commentators to say equally vile things about Sandra Fluck (the Georgetown law student who voluntarily testified before a Congressional subcommittee in early 2012 to ask for free contraceptives). I was raised in an era when it was unacceptable to say such horrible things about any woman, and believe Mahar, Letterman and Limbaugh all ought to be ashamed of themselves. But by the lights of Progressivism, since those Conservative women are acting well outside the bounds of acceptable behavior for their group (i.e., Women), making defamatory statements about them (and theirs) is no less than they deserve. Ms. Fluck, needless to say, was acting in precisely the prescribed manner, and so any negative statements (vile or not) about her are entirely verboten.

I want to emphasize the beauty of this formulation. It allows Progressives to make passionate and heart-felt – but highly selective – charges of racism, sexism, homophobia, &c. against their adversaries, while engaging in precisely the same behavior themselves, and without being in the least bit hypocritical. Hypocrisy is when one espouses certain principles, but then acts in a way that violates those principles. But the actions of Progressives in making charges of racism &c. are entirely consistent with their Diversity dogma, right down the line, and hence do not constitute hypocrisy.

To a great extent the potential worth of an individual in society is pre-determined by the group to which the individual belongs. People belonging to White Male, for instance, appear to have lesser intrinsic value to the ultimate goal of societal perfection than people belonging to Hispanic Female, even if they are particularly exemplary members of the White Male group.

Therefore, while individuals within Progressive societies can achieve a certain level of importance, individual importance is merely of tertiary concern, rather than primary or even secondary concern. Individuals can become officially “important” only if their importance reflects the essence of their assigned group; and the importance of the assigned group (the secondary concern), in turn, is proportional to its ability to advance the Progressive Program in general (which, of course, is the primary concern).

In summary, Diversity is critical to Progressivism because group identity is the best available mechanism by which the Progressive leadership can attempt to control and direct individual behaviors without resorting to violence. It is, in fact, a brilliant invention.

I know it is easy to become confused about this, since classically “diversity” means something other than “conformity.” You may find it helpful to remember a general rule about Progressives: If you want to know what Progressives are really up to, listen to what they say and then look to see if their deeds are actually working toward the opposite thing. Frequently you will find that they are.

Progressivism and Religion

Progressives have a natural aversity to organized religion. This is for three reasons. First, most major religions find a higher authority than the enlightened leadership the Progressives propose to create for us. Second, most religions are too concerned with some sort of afterlife, and insufficiently concerned with creating paradise right here on earth. And third, the major religions stress individual conscience and individual salvation over collective priorities.

Apparently realizing that abolishing religion is far too difficult a task, Progressives have adopted the long-term strategy of infiltrating and co-opting religious establishments, and by means of introducing new ideas – such as “group salvation,” and the concept of social justice as a religious imperative – rendering religion, this “opiate of the masses,” less incompatible with the Progressive Program.

Progressives do find certain religions more acceptable than others at various times. Such partiality certainly does not appear to depend in any way on the precepts or beliefs of any particular religion, but rather, on whether temporarily showing sympathy for it might in some manner advance their Program.

Good and Evil In Progressivism

In a similar vein, Progressive intellectuals are known for asserting that there are no absolutes, and so there is no such thing as inherent good or inherent evil, or inherent right or wrong. So, for instance, being against gay marriage because you believe it is “wrong” on religious grounds simply does not signify.

This general attitude toward good and evil is easily explained by the simple fact that true Progressives deny any authority, any arbiter of values, that is above their own enlightened leadership. Saying that something is intrinsically “good” or intrinsically “evil” clearly implies such a higher authority, and so, such statements must be delegitimized.

In general, this kind of moral relativism in Progressive thought holds up quite nicely, except in one area. That is the area of Progressivism itself. Because the Progressive Program is the innate agenda for mankind, there indeed exists a standard by which one can (and must) determine good and evil.

“Good” is anything which advances the Progressive Program; and “evil” is anything which threatens it.

Anyone who doubts the existence of good and evil within the Progressive Program need only observe the scores of behaviors and figures of speech which are condemned as unrelentingly evil by Progressives, with all the wild-eyed fervor of a Jonathan Edwards.

Accordingly, individuals who hinder the Progressive Program are a danger to mankind’s very essence. They are evil, and must be rehabilitated or eliminated.

Progressivism and Environmentalism

Radical environmentalism and the Progressive Program are not perfectly compatible with one another. But they are close.

Radical environmentalists believe that humanity is a plague upon Planet Earth. Everything man has done since the day he first learned to cultivate crops (and thus for the first time became a different kind of animal) has been bad. And anything which delays, halts or reverses the sins mankind has perpetrated upon sacred Gaia, since that day he first departed from Nature, is a good thing. So the radical environmentalists tend to favor strong central governments which (with the help of their Progressive allies) they can influence to control the destructive behaviors of individuals.

Progressives are certainly on board with controlling man’s effect on the environment, but (in most cases) they are not in favor of returning mankind to a hunter/gatherer condition (since most Progressives do not view this condition as the embodiment of a perfect society). Rather, they view the environmental movement – in particular, the Global Warming Theory – as a good way to get the populace to grant sweeping new powers to the Central Authority, which they can then use to carry out their Progressive Program. So Progressives have completely embraced the Global Warming Theory, chiefly as a means to their own political ends. Accordingly they have awarded it the status of Progressive Dogma, pronouncing man-made global warming to be “settled science.” They suppress any efforts to study it further, and declare anyone who dares question it to be the moral equivalent of a Holocaust denier.

This is really too bad. I suspect that global warming is occurring, and I will even concede that human behavior may be playing a role. So I am saddened that this scientific question has been declared off limits, and has been absorbed into the Progressive Program in such a way that we are not allowed to find out what’s really going on. It leaves people like me (who think the Progressive Program is deadly) little choice but to oppose the environmentalist and global warming agenda.

Progressivism and the Intrinsic Value Of Human Life

Progressivism by definition values the individual primarily (and often, solely) as a function of their value to society. True Progressives do not impart any real, intrinsic value to human life itself.

Most Progressives are reluctant to say so publicly, and it is likely that most small-p-progressives value human life as much as anyone else. But it does indeed appear to be a regular and recurrent theme of the Progressive Program to devalue human life.

Progressives will justify their belief that late-term abortion, near infanticide (killing babies who are born alive after a botched abortion), frank infanticide (proposals to allow parents to kill their recently born children if they decide they would rather not have them*), or performing involuntary euthanasia on sick people, are reasonable options by the simple expediency of re-defining what it is to be “human.” If you are truly “human,” they will say, then of course they sanctify human life. It’s just that they reserve the right to determine who is and who is not truly human, based on arbitrary and moveable criteria.
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*Giubilini A, Minerva F. After-birth abortion: Why should the baby live? Journal of Medical Ethics. March, 2012.
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The most visible example of the Progressive attitude toward the sanctity of human life is seen by their support of eugenics. Since World War II, openly espousing eugenics has become unfashionable, for obvious reasons. But eugenics, historically, has been inherently bound to Progressivism. The idea is easy to understand when you consider that, one way or another, a perfect society will require far more perfect citizens than we have today. Indeed, the seething contempt with which Progressives regard the current genetic pool that comprises the unwashed masses is often difficult for them to suppress.

To a large extent, modern Progressivism was born as an offshoot of Darwinism. The idea that society could be perfected, and the idea that mankind could be perfected, were two sides of the same coin. And early Progressives unabashedly embraced both of these ideas, such that the idea of “culling the herd” became extraordinarily attractive to them – and they said so. Theodore Roosevelt, Woodrow Wilson, Bertrand Russell, H. G. Wells, and Margaret Sanger (the founder of Planned Parenthood) are only the most well-known Progressives who publicly extolled the idea of eugenics.

One can argue, of course, whether the recent Progressive support of such activities as late-term abortions, or creating human embryos for experimentation, are partially aimed at desensitizing the public for future efforts to “guide” a more favorable genetic makeup for the population. Either way, I believe it will be useful for us to keep in mind the historic propensities of Progressivism in this regard.

It is the Progressives, after all, who, in our new healthcare system, will be determining who gets what, when and how.

Progressivism and Animal Rights

This one, I’ll admit, has been a puzzle to me. How can the same people who celebrate the right to late-term (or even post-term) “abortion” become so very exercised at the thought of mistreating a dog, or using cute bunnies for medical research, or the death of a snail darter?

I have come to the conclusion that it’s related not so much to a desire to elevate animals to the status of humans, but rather, the opposite – to help finish the job of reducing the status of individual people to that of any other animal. Again, such a diminished view of human life will come in handy as Progressives are deciding how to distribute healthcare resources.

Progressivism and Politics

Under the Progressive Program, as Aristotle says, mankind is essentially a political animal. In fact, the Progressive Program (in general) can only be achieved by political action. This means that politics – and to be clearer, political control – is the fundamental work of Progressives. Without politics, without political control, there is nothing. To lose political power is oblivion.

Not all Progressives, of course, run for elective office. Many more of them go into “public service,” wherein they spend their entire careers becoming deeply imbedded into the multitudinous governmental bureaucracies, in all three branches, and at all levels.

For Progressives, politics is everything, the essence of human behavior. And it is worth any cost, any desperate measure, to maintain political control. Indeed, to fail to lie, cheat and steal in order to keep political control would be unethical. This is why they think any proposal that would limit their ability to commit what most Americans would consider election fraud is immoral, and must be indignantly put down.

This attitude toward politics is in stark contrast to the attitude of non-Progressives, and especially of Conservatives, for whom government (and therefore politics) is merely a necessary evil, with which one must occasionally contend when it cannot be avoided. For most Conservatives politics is an afterthought.

What this means of course is that Progressivism has progressed continuously, for over a century, despite the fact that a majority of Americans still appear not to subscribe to their Program. Even in those intervals where Conservatives roust themselves into action, and take temporary control of the Presidency or a house or two of Congress, the deeply-imbedded Progressives are still there, busily gumming up the system at every level, until such time as their leaders again are in the ascendancy.

Progressivism and the Great American Experiment

Unlike any other nation in the history of mankind, the United States was not founded because of geography, race, religion or ethnicity. It was founded on an idea. It was founded on the still-radical idea that individual autonomy – the individual’s God-given right to life, liberty, and the pursuit of happiness – is the chief Fact of humankind, and that the only legitimate role of government is to create an environment in which individuals can enjoy those rights to the fullest extent possible.

One can see immediately that the Great American Experiment – which awards primacy to individual autonomy – is fundamentally incompatible with Progressivism. But because a majority of Americans still like the ideas expressed in the Declaration of Independence, the Progressives need to play their cards close to their chests. They need to proceed carefully – but relentlessly.

By slowly re-interpreting the Constitution, and slowly addicting a critical mass of Americans to an array of government programs, Progressives are certain they will ultimately prevail. They have been at it for over 100 years, and have come a long way.

I personally cannot tell whether or not we have already passed the Event Horizon, the point beyond which restoring the Great American Experiment will become impossible. But we are at least very close.

In fact, one plausible theory for President Obama’s headlong pursuit of healthcare reform (and other policies which tend to anger the majority of Americans), is that he sees America as being at the very cusp of that Event Horizon. One, last, great push – Obamacare – will sufficiently expand government control – and government dependency – to render the Progressive Program irreversible, whatever might happen in the next election or two.

In any case, whether the President’s gamble pays off or not, the Progressive assault on the Great American Experiment has at least placed it in mortal jeopardy, and mankind’s one (and possibly only) shot at creating a society in which individual rights are paramount is in grave danger of oblivion.

Progressivism vs. Socialism, Communism, and Fascism

To this point I have avoided directly comparing or contrasting Progressivism to the more commonly discussed economic and political systems of Socialism, Communism, or Fascism. And actually, I would have preferred to leave it this way. As I have said, I am not a political scientist, and so I am not as interested in relating Progressivism to these other -isms, as much as I am in simply characterizing the behavior of the people who will actually be running my life, and the lives of my family and loved ones.

But I know from experience that if I do not directly address this topic, readers with a certain frame of mind will be dissatisfied with my theory of Progressivism, no matter how well it predicts the behavior of Progressives.

So I will do my best, very briefly, to place Progressivism into its proper place relative to these other major political/economic systems.

Progressivism falls into the larger category of collectivist systems. That is, it is a political system in which individual rights and individual freedom of action are subservient to the needs of the collective, and whose chief goal is to run things for the optimal benefit of the collective whole.

Also within the category of collectivist systems are Communism, Socialism, and (some authorities maintain) Fascism.

Communism (the kind that has actually existed in various countries, not the impossible kind which Marx described) is a system in which all property is owned by the state, which in theory acts as a proxy for the “people”. The job of the state is to arrange things so as to achieve a reasonably high and reasonably equal level of “good” for everyone.

Socialism is a much broader and much less restrictive form of collectivism, since, while the state may own all or much of the property, socialism is also fine with a certain species of private ownership. Under socialism, individuals or private organizations may own even large amounts of property, but their control over that property – what they are permitted to do with it, or how they may dispose of it – is largely controlled (or “regulated”) by the state. The state also reserves the right to decide when somebody owns too much property, and has the authority to “redistribute” some or all of it, to further the goals of collective fairness (i.e., social justice).

Under Fascism, individual freedoms are also subservient to the collective goals, and the state has the right to confiscate private property any time it deems it desirable to do so. This (and the fact that Nazis referred to themselves as socialists) causes many authorities to classify Fascism as a collectivist system. But Fascism differs greatly from Communism and “real” Socialism in that the overarching goal of the latter two systems is to achieve a reasonably high and reasonably equal level of good for everyone, whereas the overarching goal of Fascism is to establish a certain faction of the population (an ethnic group, or the party) as a master race, and anyone else who is suffered to continue living as subservient peoples. So Fascism is collectivist only in the narrow sense that by the “collective” you are referring only to the favored group.

Given these constructs, Progressivism is a species of Socialism. As I have just defined Progressivism, it is in fact a fairly uniquely American form of Socialism. It is a harder-edged, more muscular form of Socialism than, say, European Socialism.

European Socialism has been the most successful form of collectivism to date. In particular, unlike other collectivist systems we have seen around the world, it has not led to violent suppression of the people by the Central Authorities. I believe this is largely because of the history of Europe – centuries of monarchies and non-mobile societies in which status was related to birthright, culminating in two extraordinarily destructive wars that deeply and directly affected virtually every member of society. This history rendered the idea of socialism (subsuming individual freedom – which had never amounted to all that much anyway – for the promise of stability and security) quite attractive to most Europeans. When Western European countries adopted Socialism, their leaders could afford to be open an honest about what they were attempting to do. And Socialism was broadly embraced by the people, to a large extent, with open arms and a sense of relief. Even today, with the European debt crisis (which is the other end-result of collectivism) threatening to wreck the entire system, most Europeans still love their brand of Socialism, and the relative (though temporary) security it has brought them.

In contrast, American Progressives have the difficult task of having to upend – as surreptitiously as possible – a foundational philosophy that is the polar opposite of collectivism; a system founded on the inalienable rights of the individual, in which the chief job of the government is to provide national security and a reasonably level playing field on which individuals can compete – and otherwise stay out of the way. It is a system that most Americans still like, and do not want to end. So the Progressives’ task has been monumentally difficult. They have had to carry out their Program without being able to say openly what their Program is really all about. Even now, when they are on the verge of success, their success relies largely on the fact that most Americans don’t realize what is about to be taken away from them.

Having to operate in the milieu of the Great American Experiment has made American Progressives – the ones who are really running things, not the large majority of progressives – hard-edged and realistic. They are not immersed in the usual bright-eyed idealism that characterizes most Socialists who first ascend to political victory. American Progressives don’t expect things to go smoothly. They have had, of necessity, to be cagy about what they were doing. They had to prevaricate. And they realize that most Americans are only slowly awakening to the realities of Progressivism. Progressive leaders know they will have to use coercion, cajoling, bribery, threats, selective prosecution, intimidation, and lots and lots of smooth talk to maintain their newly-won positions. American Progressives know what they are up against, and promise to be relatively ruthless, relatively merciless, in consolidating their authority. They have worked long and hard for this opportunity and will be ready for it, and they will be very formidable indeed.

I realize that this synthesis of Progressivism will be highly objectionable to many progressives, who honestly believe that their political philosophy is simply the fairest one there can be. To these, some of whom I have counted among my closest friends, I beg only three things. First, please take an objective look at the history of collectivist systems in the world during the last hundred years. Second, try to articulate, with an equally objective view, exactly how my synthesis is mistaken, and specifically, how it fails to explain the actual behavior we see from American Progressives. And third, ask yourself whether you are really prepared to assist in scuttling the Great American Experiment.

In any case, if there is going to be a fight to slow the march of Progressivism, it will have to be on the battleground they themselves have chosen, and on which their forces already have been fully arrayed. That battleground is our healthcare system.

This is Chapter 1 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.
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Part 1 – Progressive Healthcare, and Why We Have Chosen It

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Chapter 1 – Run For The Hills, As We Are All Doomed!

I originally meant to call this chapter, “Healthcare Economics,” but I decided that name would frighten people off.

Everyone (that is, everyone with an ounce of common sense) is frightened by economics. Economics is the index case of what happens when you attempt to apply mathematics and the language of science to what is essentially a study of human behavior. (Microeconomics, as I understand it, attempts to study the behavior of one or two guys at at time; macroeconomics purports to study the behavior of everyone, all at once.)

Human behavior will stymie anyone who tries to understand it, let alone predict it, or especially control it. (Even God, according to Genesis, became so frustrated with human behavior that on at least one occasion he was moved to wipe just about everybody out and start over. And all to no avail, one must note.)

And so economists, having dedicated their lives to studying something that intrinsically surpasses all understanding – such that even astrophysicists seem closer to their goal of understanding what happened before the Big Bang than economists are to theirs – are reduced to devising massive, complex and unlikely constructs of mathematical clockwork only they can understand, with which to pummel one another in professional meetings, in peer-reviewed publications, and on CNBC.

Oh, and they also advise our political leaders.

So I have called this chapter by a name that is far less alarming than “Healthcare Economics,” and that I hope will not send readers scurrying away. Besides, the name I have chosen is at least partially true. For it seems reasonably likely that we are indeed all doomed, though heading for the hills probably will not help very much.

Assuming that we can avoid the Really Bad doomsday scenarios that are always out there (collisions with asteroids, nuclear war, electromagnetic pulses, sudden ice ages, &c.), then the thing that is most likely to produce among us the renting of clothes, gnashing of teeth, heaping of ashes upon heads, and other behaviors commonly associated with the End Times, is the fiscal black hole we’ve made of our healthcare spending.

Our healthcare spending is sufficiently out-of-control that it produces a real threat to our survival as a society, and within many of our lifetimes. It was largely the effort to control this runaway spending that led us to adopt Obamacare in the first place, even though Obamacare (as I hope to demonstrate) promises to be almost as destructive itself.

The first five chapters of this book that comprise Part I aim to show how our healthcare system’s dire fiscal problems have led us to choose a Progressive healthcare “solution.” Here in Chapter 1, I will describe the astounding magnitude of our healthcare system’s financial mess, and how we have created it. In Chapter 2 and 3, I will survey some of the incredibly harmful changes we have made to our healthcare system in an attempt to cope with the fiscal mess. These changes have caused so much damage that, when it was time to try to choose among the four possible methods for bringing the costs of healthcare under control (which are described in Chapter 4), we finally acceded to the Progressive solution many of our elected representatives had been pining for for at least 20 years. Accordingly, in Chapter 5 I will discuss the Progressive program in general, and show why control over our healthcare is the lynchpin to the Progressives’ overarching plans for all of us.

The Fiscal Golden Age of Healthcare

Once Upon A Time, when people received a service from a physician, they paid for it themselves. Physicians who wanted to maintain a viable practice would keep their prices within the reach of their patients. And if somebody could not pay they would typically accept a reduced fee, or even a couple of chickens in exchange. During this time, healthcare was not considered a crisis, or a right, or even very important in the lives of most people.

I call this the Lancing Boils And Getting Paid In Chickens era of healthcare. It was the dark age of medicine – there was generally very little a doctor could do for you, other than lance those boils, set some but not all broken bones, and hasten your demise with leeches and bleeding. (At this point we must say a prayer of thanks that Progressives care very little about history, and so are relatively unlikely to re-discover the benefits of leeches and bleeding.) But while it was the dark age of medicine, it was the Golden Age of healthcare finance. Healthcare in those times accounted for none of our (or anyone’s) national, collective debt.

Even when inhaled anesthesia first came into common usage – making various surgical procedures such as appendectomy and Caesarian sections routinely available for the first time – the cost of healthcare was not considered a major societal problem. Somehow, arrangements were made to reimburse doctors for their services, whether through cash payments, barter, or some sort of Victorian E-Z payment plan, thus allowing the patient to avoid destitution, and the doctor to avoid the sundry nefarious activities that have always been available to cash-strapped medics.

Indeed, right up until World War II, when penicillin was discovered, physicians and their skills could offer relatively little benefit for most serious illnesses beyond the surgical variety. As a result, relatively little money was spent on healthcare. And by the traditional means of barter or negotiated settlements, or the more modern means of charity hospitals, hospitals run for their employees by the big railroad and lumber companies, or in the later years, fledgling Blue Cross plans, all the medical services that were considered useful were somehow paid for on an as-you-go basis. There was no fiscal burden placed upon society. And all was well.

Unless you got sick.

The Medical Golden Age

Conservative Americans can rant and rave about it all they want, but the fact is undeniable that the remarkable advances we’ve seen in American healthcare over the past 50 – 60 years were ushered in by a new fiscal era – an era in which we began to pay our healthcare costs collectively.

This new era was begun during World War II, when companies began offering health insurance to their employees in order to attract workers during the wage controls then in effect. Health insurance proved so popular that Congress changed the tax laws to make the insurance premiums paid by employers tax-deductible so as to encourage the practice, and before very long virtually every company provided health insurance to their employees as a matter of course.

The tax-deductibility of employer-provided health insurance was the game-changer. Healthcare costs suddenly were no longer borne entirely by individuals, or by individual businesses who paid the insurance premiums. Instead, they were distributed among the American taxpayers, whose taxes had to make up for the insurance deductions taken by businesses. So-called “private” health insurance became publicly subsidized.

The public funding of healthcare advanced by a giant step with the institution of Medicare and Medicaid in 1965, which amounted to direct public funding of healthcare for a large proportion of the population. So, by 1970, most of American healthcare was paid for by the taxpayer either directly, or indirectly through subsidized private insurance. We had largely collectivized the financing of our healthcare.

While most of my Conservative friends would like to think otherwise, when you look at the big picture it becomes apparent that this collectivization of healthcare financing has not been the unmitigated disaster they like to claim. There have been substantial benefits, and chief among these is the incredible progress we’ve made in medical learning and medical technology over the past half century.

In fact, this taxpayer subsidization of healthcare catalyzed an incredible golden age of medicine.

It turns out that, the moment everything that is deemed “healthcare” is “covered” by taxpayer-supplied or taxpayer-subsidized health insurance, and therefore payment is guaranteed for virtually any medical product by the full faith and credit of the United States government, a huge amount of investment money suddenly appears to fund research and development in every aspect of medicine you can imagine. And the next thing you know, you’ve got medical progress.

Medical entrepreneurs figured out in about a minute and a half that to be successful, all they had to do was to come up with a product that offered a measurable benefit to some group of people with some illness – no matter how marginal that benefit might be, or how expensive their product – and they were certain to have a ready market for their product and a customer who would pay the going rate without complaint. The more products you could develop, the greater your profits. And so R&D budgets went through the roof.

An utter explosion in medical progress, virtually all of it arising in the United States, began in the 1950s and 1960s, and really accelerated in the 1970s when Medicare was up and running full-bore. With a bit of sputtering, it continues until this day. Except for the Manhattan Project and the moon shot (whose fruits medical researchers strongly relied upon in doing their work), the kind of concentrated scientific effort that was applied to advance the science of medicine during this interval is unsurpassed in human history.

And like the Manhattan Project and the moon shot, it was ultimately funded by the taxpayer.

The medical technology that has been developed since the 1950s has done immeasurable good. Uncountable heart attacks and strokes have been prevented or aborted; cancers have been cured or beaten back; people who formerly would have been crippled can conduct normal daily activities without assistance; and some scourges of mankind (such as smallpox and polio) have been nearly vanquished altogether.

But there is a problem. Coincident with this explosion in medical progress has been an explosion in medical spending, spending to such a degree that, unless we bring it under control, we are headed for societal chaos.

The Magnitude of the Problem

A fundamental principle in economics is that when we are buying consumable products that we are consuming ourselves – like Caribbean cruises, sports cars, ice cream, or healthcare – we should spend no more on those products than we individuals are able to pay ourselves.

I realize that by adding healthcare to this list I have probably angered a lot of readers. But I assure you that I am not making a political statement here; I am simply stating an economic principle, which (as is the unfortunate case with principles) is inherently true even if inconvenient.

It is certainly true that some societies, including ours, have decided to purchase some of these consumable products (healthcare, for instance) collectively, so that individuals don’t pay for them at all. And the collective purchase of consumables constitutes a somewhat different situation that I will address in a moment.

But for consumable products that everyone agrees ought to be paid for by the individual (let’s just take Caribbean cruises as a relatively non-controversial example), the individual must arrange to cover the cost. The reason for this principle is obvious. If individuals could arbitrarily decide to go on a cruise whenever they’d like, but leave the cost to others who have no say in whether the cruise takes place, the economic system would soon collapse.*

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*Like most laws, principles, and ethical mandates, this one can be systematically violated by certain, small, well-defined groups of people without crashing the whole system, as long as the rest of the population (for whatever reason) decides to overlook, tacitly approve of, and pay for the irresponsible behavior of this elite group. I am referring, of course, to our political leaders.
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But what about those societies which have decided to collectively purchase certain products and services (like healthcare) that are consumed by individuals? It turns out that these societies must operate under a very similar economic principle: A society should spend no more on products which are consumed by individual citizens than it can pay without incurring long-term, multi-generational debt.

In the United States as we have seen, we have decided to pay for healthcare collectively. Whether your healthcare is provided directly through government payments or through tax-deductible insurance premiums, to a great extent society is collectively footing the bill.

This would not be a problem, economically, if we were doing it on a pay-as-you-go basis. But we’re not. We’re running a huge national debt today, and largely because of healthcare obligations that debt will reach stupendous proportions in the foreseeable future.

Reasonable people can argue over whether having a large national debt is good or bad, but the answer lies at least partially in what it is that the debt has been incurred to pay for.

The ability to borrow money, and carry debt, is important to a vibrant economy. Individuals can borrow even large amounts of money as long as they promise to pay it back and their credit rating is sufficiently high. But if a person fails to pay back what they owe according to a predetermined schedule, society takes steps to stop further borrowing and to force them to repay. If they get in too deep, society ushers them into bankruptcy, and allows them to slowly make themselves whole again. But society does not allow them to simply keep borrowing indefinitely.

This is because individuals die. If we were to allow individuals to simply accumulate as much debt as they want until they die, leaving it to somebody else to pay it back, the economic system would soon disintegrate. So before people can borrow money, they need to demonstrate their ability to repay it, or to have their estates repay it upon their death. In this way there is a natural limit to how much individuals can spend on consumable products in their lifetime.

Societies, like individuals, must borrow no more than they can eventually pay back. The difference is that, unlike individuals, society lives “forever.” That is, the accumulation of debt that cannot be paid off in a single generation is not necessarily alarming, because society will “always” be there to pay it off.

As it turns out, the ability to accumulate even huge amounts of debt is vital for complex societies like ours, as it permits us to maintain a buffer for economic stability, to smooth out boom-bust cycles, and to maintain reasonable predictability, stability, and steady growth. The ability to carry multi-generational debt enables the government to borrow the money it needs to make multi-generational investments, things like building up the nation’s infrastructure, providing for national defense, advancing medical research, and engaging in other forms of non-commodity spending that will allow society to progress, to grow stronger, and to steadily improve the lives of successive generations of its citizens.

The “right” kind of long-term national debt, then, is a chief enabler of economic growth and prosperity, an investment in the nation’s future. It is appropriate to ask future generations of Americans to share the financial burden of that debt, since they will reap the benefits of the investment.

Things go very wrong, however, when we burden society with the “wrong” kind of debt, the kind that represents an open-ended promise to purchase products and services that are consumed by individuals, such as healthcare. There are two problems with this kind of debt.

First, this kind of debt is not an investment in the future, whose fruits will be realized by our children and grandchildren, and whose returns will more than compensate for the overall debt obligation. Instead, it benefits only the individuals currently alive who are the direct recipients of the consumable services, leaving no direct benefits but only an ever-increasing debt burden to those who will be left paying the bills decades later.

Second, while there is a natural limit on how much an individual can spend for products and services they consume during their lifetime, once the responsibility of paying for those consumables shifts to society there is no longer such a natural limit (since societies live forever). The debt can now be borne by multiple generations. Because there is no longer an inherent limit to what an individual can consume, and because it is to the advantage of present and would-be officeholders to eliminate any remaining arbitrary limits, individuals are eventually encouraged to consume as much as they want. And without these limits (whether natural or imposed by rules) the provision of such services to individuals rapidly becomes an entitlement, whereupon the natural checks and balances that (in past times, at least) apply to other parts of the federal budget are no longer available.

When society faces an accelerating debt burden that is completely open-ended and is not subject to normal checks and balances, that society is dealing with a “disproportionate economic variable” (DEV) – that is, an economic obligation that grows without limit and completely out of proportion to the growth of the overall economy. Healthcare spending, which unrelentingly consumes an ever-increasing proportion of our GDP, is such a DEV.

DEV’s are inherently destructive to a society, and for that reason they are typically rare. Indeed, in viable societies the only commonly encountered DEV is wartime spending, where a disproportionate amount of a society’s wealth must be spent in the violent struggle for survival (or, alternatively, in the violent struggle to take away valuable resources of the opponent in order to power future growth, in which case war is analogous to a high-risk start-up). Indeed, the disproportionate spending in wartime is tolerable only because war itself is temporary. It should be noted, however, that one reason war is temporary is that in a prolonged war, a runaway DEV can cause a country to spend itself into oblivion. (See: the multi-decade Cold War and the demise of the Soviet Union.)

Until the time we began to collectivize our healthcare expenditures, healthcare spending in the United States acted like any well behaved economic sector. That is, until the 1950s healthcare spending remained at a steady 4% of the GDP. But by 1960, healthcare spending had become a DEV. Healthcare spending was at 5.3% of the GDP in 1960, 7.3% in 1970, 10.2% in 1980, 13% in 1993, 14.9% in 2002, and 17.6% of the GDP in 2009.

We already cannot afford to pay-as-we-go for all the healthcare we’re consuming. Instead, we’re violating that economic principle I mentioned earlier, and accumulating massive amounts of federal debt to cover the cost ($16 trillion at last count, enough that we’re already flirting with fiscal brinkmanship), which we are leaving to future generations to figure out how to pay off. And it’s about to get much worse.

Assuming we survive credit downgrades, the European debt crisis, oil disruptions in the Middle East, and other more routine difficulties, the most immediate fiscal threat to our economic survival becomes apparent when you think about all the expensive medical technology we’ve managed to accumulate over the last 50 years, and imagine applying it to our rapidly aging population, that is, to the baby boomer generation – which (I can personally assure you) is planning to make exuberant use of all this stuff. The magnitude of this problem is actually pretty easy to estimate.

Consider: All the people who will constitute our population of Old Farts for the next 30 years (a group which already claims your humble author as a proud member) are alive today. We can count them. We can also enumerate the quantity of many of the various illnesses and ailments they will suffer – the strokes, heart attacks, heart failures, Alzheimer’s disease, hip replacements, cancer, drooping body parts and ED – with fair accuracy. And we can estimate reasonably closely (if our leaders succeed in stifling medical progress, and therefore medical technology is held at its current level) what kinds of drugs, devices, nursing care and other expensive medical appurtenances they will require. And with this information we can add up all the sums and multiply all the multipliers to estimate what it’s all going to cost us.

Indeed, the GAO has done this. It’s looking like it will cost $30 – 40 trillion over the next several decades, just to cover the medical entitlements which we have promised current and not-too-distant-future older Americans, Americans who have themselves been paying taxes for many years, and who have arranged their affairs according to the expectations created by those promises.

That’s way more money than it will take to cause societal collapse.

Can’t We Just Eliminate Waste and Inefficiency?

In Chapter 4, I will talk about the four ways that are available to reduce this dangerous level of healthcare expenditures. You may be surprised to learn that none of these four methods is to eliminate all the waste and inefficiency in our healthcare system.

I am in favor of eliminating waste and inefficiency, of course, and I applaud most efforts to do so. But eliminating waste and inefficiency did not make the list of four for a simple reason. It will not work. That is, even if we somehow got rid of all the wasted healthcare expenditures taking place today (and there truly is a tremendous amount of it), that won’t be enough to rescue us from economic oblivion.

This is not a pleasant thing to hear, nor is it a common thing to hear. Indeed, it is a central assumption of all of the healthcare reform plans ever proposed that we can get our spending under control simply by eliminating – or at least substantially reducing – the vast amount of waste and inefficiency in the healthcare system. Conservatives propose to do this by incorporating the efficiencies of the marketplace, thus eliminating the waste and inefficiency imposed by government bureaucrats. Progressives propose to do it by adopting and enforcing strict, top-down regulations (ideally, through a single-payer system which employs the officially-perfect wisdom of various expert panels) that will control the wasteful and inefficient behaviors of greedy and/or ignorant healthcare providers. But one way or another, schemes for reforming healthcare all propose to bring spending under control by eliminating waste and inefficiency.

Another way of describing what all the reformers across the political spectrum are telling us is: There is so much waste in the system that we can avoid healthcare rationing by getting rid of it. Most Americans believe this. Most policy experts believe this. They have to believe it, because nobody wants to even think about healthcare rationing.

But this is unfortunately false. No matter how much waste and inefficiency you think might be gumming up our healthcare system today, there’s not enough to explain the uncontrolled rise in healthcare spending we have been seeing for decades, and therefore, not enough to allow us to avoid rationing altogether in any economically feasible, publicly funded healthcare system.

To understand why this is the case, we must first recognize the fundamental problem with our healthcare spending. The real problem is not simply that we’re spending a lot of money on healthcare, or even that we’re spending a larger proportion of our GDP on healthcare than any other country. If that’s all the problem was, we could with modest difficulty adjust the rest of our spending to accommodate it, and get our national budget under control that way.

Rather, the real problem is that our healthcare expenditures for decades have been growing at double digit rates, several multiples faster than the overall inflation rate, and each year consumes an ever-greater proportion of our national spending. Unless this disproportionate rate of growth is stopped, eventually healthcare spending will cannibalize our entire economy. (What will really happen, of course, is that the debt we are accumulating to pay for our healthcare will grow to the point of producing societal upheaval, sending us back to a more typical era for mankind, where healthcare is a little-thought-of luxury, and not a necessity or a right. This will happen well before healthcare consumes 100% of the economy.)

To reiterate, it’s not the amount of spending on healthcare that is creating a fiscal crisis, it’s the rate of growth of that spending.

Once we understand the problem – that it’s the rate of growth of healthcare spending that threatens our society – then demonstrating that waste and inefficiency cannot possibly account for that rate of growth is a matter of simple mathematics.

There are only two things that can possibly account for the excessive growth rate of our healthcare expenditures. Either it is caused by unrelenting growth in wasteful spending (as we are assured by our political leaders), or it is caused by unrelenting growth in useful healthcare spending. If it is the latter, then in order to get spending under control in a collectivized payment system we must cut back on or ration useful healthcare. This is why we all fervently pray, and most of us choose to fervently believe, the excess rate of growth must be caused by wasted spending.

This desired conclusion, unfortunately, leads to mathematical absurdities, and therefore (for anyone who eschews magical thinking) turns out to be utterly false.

I am going to show you some data from a spreadsheet. My spreadsheet illustrates what would have to happen in order for wasteful spending to account for our current level of healthcare inflation. The spreadsheet is based on the following four assumptions:

Assumption 1) The annual growth rate of spending on useful healthcare (discussed further below) is economically well-behaved. That is, it matches the rate of overall inflation. The spreadsheet therefore assumes a 3% annual inflation rate for useful healthcare spending.

Please note that this is the very assumption which politicians invoke whenever they say that all we need to do to control healthcare costs is to eliminate waste and inefficiency. In fact, the whole point of this spreadsheet is to test the logic of this assumption. For, if useful healthcare spending is not economically well-behaved, then eliminating all the wasteful spending would still leave us with disproportionate healthcare inflation.

Assumption 2) 25% of healthcare expenditures at Year 1 of this spreadsheet are wasteful. I have picked 25% arbitrarily, a value that happens to fall within the range of popular estimates. As it turns out, the initial value we choose for the level of wasteful spending at Year 1 in this spreadsheet has very little influence over the outcome. So if you don’t like this number, feel free to pick your own.

Assumption 3) The annual rate of growth of overall healthcare spending (i.e., healthcare inflation) is 10%. This is a rough average of what we have actually seen for the last few decades.

Assumption 4) Total healthcare inflation is the sum of healthcare inflation due to the growth of “well-behaved,” useful healthcare spending, and the healthcare inflation accounted for by spending on waste and inefficiency. Given that the inflation rate for useful healthcare spending is 3% (Assumption 1), this spreadsheet simply calculates the cumulative annual inflation rate for wasteful spending that would be necessary to account for an overall rate of healthcare inflation of 10% (Assumption 3).

Before I show you the spreadsheet, we should discuss the difference between “wasteful” and “useful” healthcare. In actual practice, this is not a distinction which is straightforward. It depends, for one thing, on who gets to define “wasteful.” If I’m a 92-year-old man who gets a $12,000 stent procedure to eliminate my angina, I and my doctor might consider it money well-spent, while you might consider it wasteful.

But for the purposes of this present analysis, I am defining “wasteful” healthcare in the way our politicians define it – or at least in the way they want us to think they are defining it. That is, wasteful healthcare is completely wasteful – it is a totally useless expenditure, and is no more beneficial than flushing money down the toilet. In contrast, useful healthcare is that which is likely to provide at least some of its intended benefit to patients.

Any other definition of useful vs. wasteful healthcare would require us to place a value judgment on just how much benefit a healthcare service must provide before we consider it to be useful, and thus worthy of paying for. Another name for such a process is “rationing,” and we all know that we’re not going to do any rationing. No, sir.

So, the definition we must use for “useful” vs. “wasteful” healthcare, by process of elimination, can only be the definition I have just laid out.

Here is the spreadsheet:

Year	Index of overall Dollars Spent per year	% wasteful spending	% of annual increase due to useful spending	% of annual increase due to wasteful spending
1	100	25%	-	-
5	146	42%	18%	82%
10	236	59%	13%	87%
20	612	78%	7%	93%

We can immediately see several things. First, as expected, the amount of money we’re spending on healthcare, assuming a rate of healthcare inflation of 10%, is doubling roughly every 8-9 years. It’s this growth rate that threatens our survival as a society.

Second, in order to account for this unsupportable growth in healthcare spending by invoking waste and inefficiency, the proportion of healthcare spending that is caused by waste must increase to ridiculous proportions very rapidly, such that (for instance) by the 10th year we will have more than doubled (59%) the proportion of all healthcare expenditures that are wasteful; and by the 20th year, nearly 80% must be wasteful.

Similarly, the proportion of the annual increases in healthcare spending that would have to be due to waste and inefficiency rapidly climbs to equally ridiculous proportions. By year 5, wasteful spending will have to account for 82% of the annual increase in healthcare expenditures, and that proportion continues to climb, eventually approaching 100%.

To me, these numbers seem absurd on their face. But if you still need to be convinced, consider that in real life, runaway healthcare inflation has already been taking place in the United States for decades – so our position on such a spreadsheet would not be at Year 1; we are much closer to Year 50. And no matter what value for wasteful spending we might have plugged in at Year 1, by Year 50 wasteful spending would have to be well above 80%, and more likely approaching 100%. In order for waste and inefficiency to account for the situation in which the American healthcare system finds itself today, therefore, one would have to believe that virtually all healthcare spending is wasteful. (And if you believe that, then solving the crisis would be a simple matter of discontinuing all healthcare.)

Now let us illustrate the same point in a slightly different way. This time, let’s pretend that as recently as 2009, when President Obama was inaugurated, our healthcare system was 100% efficient. That is, only three years ago there was no waste whatsoever. Then let’s allow that the remaining three assumptions given above are still operative. The following table results:

Year	Index of overall Dollars Spent per year	% wasteful spending	% of annual increase due to useful spending	% of annual increase due to wasteful spending
2009	100	0%	100%	0%
2010	110	7%	30%	70%
2011	121	15%	28%	72%
2012	133	17%	26%	74%

We can see from these results that, even if only three years ago we had a completely efficient healthcare system, in order for waste to account for the excess growth in healthcare spending we’ve experienced since that time, then after just three years as much as 74% of today’s annual increase in spending has to be due to waste and inefficiency.

Any way you cut it, the spreadsheet leads to nothing but absurdities. Assumption 1 – that useful healthcare spending is economically well-behaved – therefore cannot be true.

Wasted spending may and likely does account for a significant proportion of our healthcare expenditures, but it simply cannot account for the sustained, disproportional growth in healthcare expenditures that threatens to collapse the system.

So yes, by all means, let’s try to eliminate waste and inefficiency from our healthcare system. But if we hope to survive as a culture, we will, at the same time and as an entirely separate endeavor, have to figure out how to get the growth in useful healthcare spending under control.

Summary

It is critical to understand that a fundamental, nearly intractable, doomsday-magnitude fiscal problem with our healthcare spending preceded Obamacare, and continues today. That fiscal problem will remain whether we proceed with Obamacare or not. Simply striking it down in the courts or repealing it will not help fix the underlying problem.

Podcast:

In his last post, DrRich demonstrated that our modern American healthcare system proposes to treat individual patients as if they were merely members of a herd of cattle or sheep.*

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*Doctors, on the other hand, will be treated like the border collies who – responding instantly to the various complex whistles, hand gestures, and occasional (less complex) kicks administered by their masters – will keep the herd nicely organized into manageable clusters.
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But we should take note that this systematic, official devaluation of individual worth was not produced out of whole cloth by the Obamacare legislation (nor would it be completely overturned by its repeal). Rather, it has been in the works for several decades, the natural, evolutionary result of a philosophy of healthcare that was all the rage until just a few years ago, but which – mysteriously – we seem to hear very little about these days. DrRich speaks, of course, of managed care.

Like many of the current travesties taking place within our healthcare system, managed care began with a pretty reasonable idea; namely, to apply certain management principles to the healthcare system that have been used successfully in other industries, thereby injecting logic, organization, and accountability to what had been a bastion of disorganization and inefficiency.

The unifying idea behind managed care boils down to one word: standardization. Standardization is virtually a synonym for industry. In industry, standardization is the primary means of optimizing the two essential factors in any industrial process: quality and cost.

This proposition can be stated formally as the Axiom of Industry:

The standardization of any industrial process will improve the outcome and reduce the cost of that process.

If you had a widget-making factory, you would break your manufacturing process down into discrete, reproducible, repeatable steps and then optimize the procedures and processes necessary to accomplish each step. To further improve the quality of your finished product (or to reduce the cost of producing it), you would reexamine the steps, one by one, seeking opportunities for improvement. You would need to understand the process thoroughly, and you would need to collect data about how well the process works. But with the right information, you could almost certainly identify a few minor changes to improve the manufacturing process. The beauty in such a system is that you have only to make one change — to the process itself — and every widget that comes off the line after you make that change will be improved.

So standardization is good. It leads to higher quality and lower cost. Conversely, variation is bad. It reduces quality and raises cost.

Proponents of managed care argued that standardization should be just as useful in healthcare as it is in other industries. As medical care has traditionally been individualized, highly variable, and without any semblance of standardization, there must be a huge opportunity to improve the processes of care and to make them both cheaper and more effective. There is obvious merit in such an idea.

Perhaps the most direct, and the most successful, application of managed care practices to modern medicine was the adoption of “critical pathways” in the 1990s.

Critical pathways are blueprints for delivering standardized care to patients with specific medical problems. Consider a critical pathway for hip replacement surgery. The critical pathway is a specific schedule of which services are to be provided for the patient and when, from the date of hospital admission until the date of discharge (which is, of course, predetermined). Checklists are created for which laboratory tests to order and when, which medications to administer at which times, and which specific complications to check for. Everyone involved in the patient’s care has their own relevant checklist. From the moment of the patient’s hospital admission, the critical pathway predetermines when to take vital signs, when to get the patient out of bed, when to begin physical therapy, and when to provide standardized instructions to the patient before discharge. Every vital service is included, and all extraneous services are omitted.

A “case manager” monitors the care each patient receives under the critical pathway. Every deviation from the prescribed procedure is tabulated as a “variance.” Variances are tracked not to decide who to punish, but to identify areas of the process that need improvement. If too many instances of a particular variance are seen in a critical pathway, then either medical personnel need to be retrained on following the pathway appropriately, or the pathway itself should be changed to reflect more realistic expectations.

Critical pathways, in fact, proved to be extremely helpful in many cases. But of course there were some drawbacks and limitations.

First, critical pathways are only useful for delivering medical services, like elective surgery, in which the process of care can be broken down into a predictable series of discrete, reproducible tasks that generate reproducible results. In other words, industrial management tools only work when the process of care is similar to the process of making widgets.

Critical pathways are almost worthless when you are dealing with medical illnesses in which neither the diagnostic procedures nor the treatments that may be employed can be predicted or, therefore, standardized. For instance, it has proven impossible to develop workable critical pathways to manage patients with congestive heart failure (CHF). Knowing only that a patient has been admitted to the hospital with CHF tells you nothing about whether that patient will require cardiac catheterization, a stent, bypass surgery, valve replacement, a pacemaker, an implantable defibrillator, a mechanical ventilator, a prolonged and complicated stay in the intensive care unit, or just a couple of diuretic tablets and overnight observation. No two patients with CHF are alike; and there is no such thing as a standard patient. Unfortunately, most non-surgical medical services fall into this category.

Second, it turns out that when you are taking care of patients, the Axiom of Industry simply does not hold true. Standardization does not always improve outcomes and reduce cost. The reason for this is: Patients are not widgets. And while in theory everyone seems to agree that patients are not widgets, the implications of this fact appear to escape many of our public health experts.

If you’re a widget maker, deciding between two manufacturing processes is a matter of economics. Nobody expects you to consider the widget itself. The outcome by which you are judged has nothing to do with how many individual widgets get discarded during the manufacturing process or even the quality of the widgets that pass final inspection. Instead, it’s the bottom line: how much profit you make in relation to whatever level of quality you put into the widget. So the quality of the widget is not necessarily maximized, instead it’s optimized, tuned to the optimal quality/cost ratio as determined by the market forces of the day. This is why, for a widget maker, the axiom holds: standardization, by rooting out variability, reduces the cost of making the widget (whatever quality level you choose). This automatically improves the outcome, because the outcome the manufacturer cares about is overall profit.

If instead of running a widget company you’re practicing medicine, the calculus is supposed to be different. You’re supposed to be more interested in how things turn out for individual patients than you are in the bottom line. So an expensive process that yields a better clinical outcome is one most people (patients, at least) would expect you to use, even though it only gets you a healthier patient and doesn’t help your bottom line. A process that increases patients’ mortality rate by five percent is one you should disregard, even if it is substantially cheaper than the alternative. The clinical outcomes experienced by patients — the measure of success you’re supposed to be concerned about — may move in the same direction as costs, or in the opposite direction. But because you’re dealing with patients instead of widgets, the Axiom of Industry doesn’t hold – and outcomes and costs do not always move in the same direction.

So the push to strictly apply managed care techniques to healthcare created a dilemma for doctors. Doctors – the widget-makers in this scheme – tried diligently to apply standardized procedures such as critical pathways to the care of their patients. But the more un-widget-like the medical services they were providing, the more often they were compelled to make “exceptions” to the prescribed standardized process, in order to best serve their individual patients.

Such exceptions are a legitimate and valued aspect of any industrial process. In the widget-making world, exceptions reveal that the process needs to be tweaked to make it more usable. Exceptions lead to further iterations and refinements of the process, and a steadily improving result. Exceptions are what allow these industrial processes to become self-correcting.

But in the messy world of patient care, the exceptions revealed instead that industry-like standardization only works for a minority of medical services. No amount of tweaking can standardize the management of complex patients with complex combinations of illnesses.

It did not take long for doctors to simply stop attempting to use critical pathways for non-widget-like medical services. They did this because they actually cared about what happened to the individual widgets in their charge.

Similarly, it did not take long for our public health experts to recognize the same problem. From their standpoint, however, the problem was not that patients are not widgets. The problem was that the doctors on the scene cared about the widgets. Further analysis revealed that the root of the problem was that classic managed care techniques were administered locally, and therefore the misguided loyalties of the doctors on the scene were allowed to rule the day.

The reason we don’t hear about managed care anymore is that such terminology refers back to those locally-administered, iterative, self-correcting, continuously improving industrial processes. And our public health experts have now realized that this model does not work, and must no longer be encouraged.

The solution to the widget-makers dilemma is to remove the dilemma. Since a dilemma requires one to choose between two bad options, any dilemma can be resolved by simply removing the choice. And this is what has now been accomplished.

There is no dilemma for physicians any more. Clinical decisions are now to be made centrally, through the “guidelines,” handed down by GOD panels (Government Operatives Deliberating), which will prescribe precisely who is to get what, when and how. Doctors are now enjoined, both by law and by the new medical ethics, to follow those “guidelines” to the letter, without exception.

Whoever thought that some day we would fondly recall managed care as the good old days?

Podcast:

On the same day that DrRich published his post about the American College of Physicians’ new Ethics Manual, Rob Stein of NPR’s Health Blog did the same thing. In his post, Mr. Stein took particular notice of the ACP’s admonition to physicians that, in order to practice medicine ethically, they must practice parsimoniously.

DrRich flatters himself to believe that he may be the one who called Mr. Stein’s attention to this remarkable terminology. Mr. Stein had contacted DrRich just prior to the New Year’s holiday for his reaction to the new Ethics Manual – and DrRich responded with a lengthy e-mail containing a substantial riff on the ACP’s usage of “parsimonious” (a riff that was not dissimilar to the one appearing here on the CRB a few days later).

In any case, whether DrRich had anything to do with his focus or not, Mr. Stein (being a reporter instead of a mere ranter) actually interviewed several persons of interest regarding this curious terminology. Dr. Scott Gottlieb of the American Enterprise Institute and Daniel Callahan of the Hastings Center appeared sympathetic to DrRich’s take on “parsimonious,” that is, that this word, at best, carries some very negative connotations under any circumstance, but particularly when it is used in the context of providing healthcare to people who need it. (DrRich himself was not mentioned in the NPR article. This undoubtedly shows good judgment on the part of Mr. Stein, who has his reputation to think of.)

The most interesting response to Mr. Stein’s questions on “parsimonious” was offered by Dr. Virginia Hood, current president of the ACP. She strongly defended the use of the word, saying, “Parsimonious is a good word in the sense that it means that you use only what’s necessary. I don’t see a particular problem with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

So the mystery raised by DrRich in his last post is apparently resolved. When the ACP says “parsimonious” it turns out they are not referring at all to the “theory of parsimony” (or Occam’s Razor), the theory which states that when there is more than one explanation for a series of observations, one must always default to the simplest available explanation. It seems a shame that this is not what the ACP was referring to. While it would have been terribly misguided for the ACP to make an unqualified demand that doctors apply the theory of parsimony to all questions that arise in medical practice, at least they would have seemed somewhat sophisticated in doing so. For many academic papers have been written about the theory of parsimony, and some of them border on the esoteric.

But astoundingly, that’s apparently not what the ACP meant at all. It turns out that what they meant was, in fact, parsimonious. Dr. Hood purports to believe that “the real meaning of the word” is “efficient.” But she should know that it is not. According to Roget’s II New Thesaurus, parsimonious is “ungenerously or pettily reluctant to spend money.” Webster’s New World Dictionary gives “stinginess, extreme frugality.” Other sources DrRich has found list similar definitions, such as: excessively unwilling to spend, penny-pinching, miserly, sparing, grasping, tight, close, niggardly, illiberal, mean, avaricious, covetous, rapacious and tight-assed. Only one source even mentioned the word “efficient,” and it was the 15th or 16th meaning. The dictionaries make it clear that being “parsimonious” is not a thing to be admired.

Students of philosophy, religion, and psychology have known, at least since Dante, that a vice is a virtue carried to extremes. The vice of lust is a perversion of the virtue of love. Servility is a perversion of humility. Recklessness is a perversion of courage.

And parsimony (or miserliness, or stinginess, or any of the many synonyms that exist for this very common vice) is a perversion of thrift. We do not celebrate the addled stalker because his vice is rooted in a perverted form of love. We ought not celebrate parsimony because, despite its perversion into something awful, it is based on efficiency.

Notwithstanding Dr. Hood’s protests to the contrary, when the ACP admonishes physicians, as a matter of ethics, to provide healthcare parsimoniously, that is not a good thing.

While Dr. Hood may herself not be a lexicographer, DrRich thinks we can be fairly certain that, for a document like the ACP’s Ethics Manual, before final publication each and every word is carefully parsed, analyzed and considered by a number of astute and highly educated individuals. Indeed, one notes that the lead author of this document is an attorney, and attorneys are notorious for understanding every nuance of every word they allow into written documents. One would assume that this is especially true for a word which is so important to the message that it is being placed in a special call-out box, so nobody will miss it. It is simply not believable that “parsimonious” – which describes a well-known vice – managed to slip into this document inadvertently as a synonym for “efficient,” as Dr. Hood suggests. That explanation, of all the possible explanations, is simply not credible.

So perhaps Dr. Hood misspoke, and “parsimonious” really was referring to the theory of parsimony after all, and she either did not realize this (not being a lexicographer), or simply forgot. The only other credible explanation, which Dr. Hood indignantly denies, is that the ACP actually does mean for doctors to practice medicine parsimoniously – with all its negative connotations – and that her present dissembling is merely dissembling.

As it happens, DrRich has a brief history with Dr. Hood. Two years ago, the Covert Rationing Blog and the ACP Advocate Blog were both named as finalists for a Medical Weblog award in the category of Health Policy and Medical Ethics. So DrRich suddenly found himself in an ethics competition with the very organization that had published the notorious “New Physician Charter on Medical Professionalism,” and thus had destroyed the very foundation of medical ethics.  He could not resist the opportunity to publicly challenge the ACP, under the spotlight (and protection) of the Medical Weblog competition, to an open debate on medical ethics.

You can read all about the ensuing exchange here. What may be of some interest for our present purposes is that it was Dr. Hood herself – at the time the Chairperson of the ACP’s Committee on Ethics, Professionalism, and Human Rights – who finally drafted the ACP’s public response to DrRich. And interestingly, in her response (which was heavy on condescension but light on logic) Dr. Hood invoked the need for parsimonious care. So the ACP’s use of this word was not a momentary oversight; instead it has been rolling off their collective tongues for years, as a descriptor for what they consider to be the ideal approach to the practice of medicine.

Another aspect of that Medical Weblog competition between DrRich and the ACP is more to the point at hand, namely, the interesting manner in which the ACP finally beat DrRich out for the award. The way the competition works is that a short list of finalists is determined by a committee of judges, and then for two weeks anyone who is interested can vote for their blog of choice. The voting system allows only one vote per IP address (so if 20 people all vote from their computers tied into a company network, only one vote is counted). During the voting period, a running tally of results is shown to anyone who cares to see it.

Clearly, given the public spectacle DrRich had made regarding the righteousness (or lack of it) of the ACP’s stance on medical ethics, it would have been deeply embarrassing for the ACP to lose this medical ethics contest. So it was probably troubling to that organization when DrRich mounted a substantial lead early on, and held that lead for two weeks, right up until the last three hours before the voting ended, which, as it happened, occurred at midnight on Sunday, February 14. Then, late on Valentine’s night, when most normal people were with their loved ones doing, well, Valentiney things, apparently a large number of ACP members spontaneously rousted themselves from their activities, logged on to their computers, and voted for the ACP – just enough of them to overtake DrRich, and then to maintain a steady 10 – 20 vote lead for the remaining hour or two of the voting period.

DrRich is not relating this story because he is bitter, nor is he complaining. (This blog won the Medical Weblog award the following year, so there is nothing for DrRich to complain about.) Rather, he was and is deeply amused by these events, and he relates this story for a very pertinent reason – namely, for the purpose of illustrating the shortcomings of the “theory of parsimony.”

For what are the possible explanations for the ACP’s stunning last minute victory? One explanation is that, in the waning moments of Valentine’s Day, members of the ACP finally got around to voting. This is of course possible. These are internal medicine specialists, and many of them are the guys (and girls) you knew in college who looked forward to football Saturdays because the library would always be so much quieter. So it is indeed possible that the ACP membership had entered into their iPhones, weeks earlier, a reminder to vote for the ACP at 11:59 PM on Sunday, February 14. Perhaps they figured they would be logged on to their computers at that moment anyway, reading the latest research on the complement cascade.

Another possible explanation is that someone affiliated with the ACP, realizing how deeply embarrassing it would be to lose an ethics contest to a pain in the ass like DrRich, figured out a way to defeat the voting system’s firewall, and to enter the precise number of votes they needed at the last minute in order to gain a victory and save face. We have seen examples in electoral politics, over and over again and perhaps as recently as last Tuesday night in Iowa, that in close contests it is best to withhold a bolus of the votes you control until the last minute, when you know just how many votes you need.

DrRich is not accusing the ACP of anything, of course, as he has no direct proof that they behaved badly – just a series of observations that have more than one possible explanation. But he admits to finding it delicious that a straightforward application of the theory of parsimony – always choosing the simplest explanation for a series of observations – leads us to the conclusion that agents of the ACP apparently cheated in order to win an ETHICS contest.*

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*If they actually did this, of course, some would say it would indicate that the ACP has disqualified itself from ever establishing ethical rules for anyone.  But actually, it would simply be another illustration of utilitarian ethics, where important ends always justify whatever means are necessary to achieve it.

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Since we know beyond doubt that the ACP would never have done such a thing, and that the ACP won that competition fair and square, DrRich has therefore just demonstrated that applying the theory of parsimony, after all, will often enough lead to incorrect conclusions, and therefore the ACP ought not demand that doctors apply it as a matter of course in all questions of life and death.

So either way, whether the ACP’s use of the word “parsimonious” was supposed to indicate that doctors ought to be stingy and miserly in delivering medical care, or whether they were obligating doctors to always apply Occam’s Razor to medical decisionmaking, delivering parsimonious medical care is a very bad idea, and certainly ought not to be an ethical mandate for physicians.

The leadership of the ACP ought to know this. Indeed, Occam’s Razor suggests that they do know this, which would be the simplest explanation for why, when challenged on their choice of the word “parsimonious,” they insist that they mean the one thing that makes no sense whatsoever.

Podcast:

In the tradition of “Yes, Virginia, &c.,” DrRich once again reprises his classic holiday message.

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‘Tis once again that time of year when we Americans gather together with our extended families and friends to celebrate the Season. It is a time for catching up – renewing acquaintances and making new ones, sharing in good news and commiserating in bad, welcoming our new arrivals and mourning our losses. It is a time for giving thanks, counting our blessings, and putting our sundry individual problems into perspective. Indeed, it is perhaps most importantly a time for each of us to remind ourselves that – despite the trials and tribulations that may cause us to become relatively self-absorbed in our daily lives – we are all part of something much greater than ourselves.

So, in a way, it’s a shame we must now cull out our obese relatives and friends, and disinvite them from these joyful and fortifying reunions.

It’s not something we should do lightly, as the obese are people, too. They enjoy the holiday gatherings as much as anyone else (more, some would say, given the abundance of sugary foodstuffs which are typically provided there). But alas, excluding the obese is now something we must do – for our own sake, of course, but more importantly, for the sake of our social networks, and indeed, for America itself. For, to allow the obese to continue participating in our traditional seasonal gatherings is something we now know (as DrRich will shortly explain) to be simply too dangerous and too counterproductive to our collective interests. We can no longer permit it.

Before demonstrating why, DrRich ought to digress for just a moment to address the burning question many of his kindly and generous readers must already be asking, namely, What about Diversity?

On the surface at least, it would seem that the exulted goals of Diversity – the uber virtue, from which all the other, more subsidiary virtues must necessarily spring – would be well-served by our including the entire panoply of body types in our holiday celebrations, from the very thin to the very fat. Must we really exclude from our table our obese family and friends, whom we know and may love, while at the same time, in the name of Diversity, welcome into our collective bosom, say, self-declared Islamist terrorists who openly aim to kill us?

In a word, yes.

For the terrorist, as much a danger to our persons as he or she may pose, is merely a fervent adherent to a minority (and therefore oppressed) religious sect, whose fundamental beliefs (though they center around the utter destruction of Western Civilization) we may not legitimately place ourselves in a position to judge, and therefore, whose tolerance by us, and proximity to us, greatly enriches our appreciation of the wondrous diversity of the human experience.

In contrast, obese people are just fat.

They have no redeeming qualities whatsoever which ought to merit their protection under the beneficent umbrella of Diversity. In this way, fat people resemble Sarah-Palin-lovers, global warming skeptics, tea party fanatics (at least 40% of whom, by the way, are overweight or obese, judging from photos of their rallies), and other groups of narrow-minded or otherwise inferior people the benign tolerance of whom would quite obviously do material harm to the true goals of Diversity. But the obese pose a greater threat to us than even these other unworthies do.

And unfortunately, as we approach that charitable season in which our natural inclination would be to temporarily overlook the sins of our obese friends and relatives, to allow ourselves to fraternize with these individuals – even if only for a few brief hours during this one time of year – is to place ourselves, our non-obese loved ones, and our nation itself, in immediate and immeasurable peril.

This sad fact came to light just a few years ago when a landmark study was published in the New England Journal of Medicine proving that obesity is contagious. Merely having fat friends (and not necessarily living with or near them, or even interacting with them regularly, but merely enumerating them among your friends at a distance) can make you fat as well.

The study came from the studios of the famous Drs. Christakis and Fowler, who have embraced a software package, comprehensible only to themselves, that churns out complex images of “social networks,” from which they can derive all manner of heretofore unimagined associations. These academic stars have turned their shop into a veritable factory of peer-reviewed publications, thereby solidifying their scholarly reputations and (doubtless, now that they have done so much good for the anti-obesity movement) their ability to secure NIH grants, and other favors from government agencies.

Using data from the venerable Framingham database, these pioneers combed through old records for information about the body weight, relatives, and social contacts of individuals who were enrolled in this famous study. They then used their esoteric computer modeling software to create various “animations” depicting the evolving social relationships of the subjects, and the development of obesity, over time.

To summarize their findings: A person is 57% more likely to be come obese if a friend becomes obese, even if that friend lives hundreds of miles away. (This finding is really quite remarkable, considering that the only other natural force that acts on bodies instantaneously and at a distance is gravity. This newly discovered force that produces obesity at a distance – shall we call it “obevity?” – will have to be incorporated, with great difficulty no doubt, into the Grand Unification Theory now being sought by physicists everywhere.) The same effect was not seen when close neighbors became obese, or even (to such a great extent) when family members became obese. Furthermore, if the friendship is mutual (that is, if the fat person considers you a friend in addition to you considering the fat person a friend), the odds of your becoming obese triples. And even worse, this study shows that, even if you wisely avoid the company of fat people yourself (in an attempt to remain acceptably svelte), fat people who are acquainted with your acquaintances may still have an impact on your BMI. That is, obesity is a contagion that tends to spread throughout the social network.

So clearly, if anyone within a given social network associates with fat people, then ultimately nobody in that network is safe.

(Here is an animation the authors have provided, to show a time-lapsed view of how obesity spreads. If this doesn’t convince you, nothing will.)

Now, to be sure, there have been critics of this study – individuals, DrRich thinks, who are nearly as dangerous as the obese themselves. Since this issue is so critically important, please allow DrRich a few brief paragraphs to debunk the debunkers.

Some have complained about this landmark study because the list of “friends” employed by the authors was determined decades after the fact, from administrative records that had been used in the Framingham study for follow-up purposes, in which subjects had been asked to list relatives and a “close friend” who would know their whereabouts at all times. Critics claim that somebody who can reliably provide your contact information may be a good friend; but perhaps not. Perhaps subjects were simply more inclined to give the name of a fat person as a round-the-clock contact. After all, it’s always easier to get ahold of an obese person who, being slothful, is likely to be parked in front of his TV, popping chocolates and munching chips, than it is to contact somebody who’s thin, and is likely to be out and about, probably jogging. The researchers, in other words, were not operating from a list of BFFs, but instead from a list of acquaintences judged by the subjects at the time to be most likely available by telephone. (The subjects, remember, had been enrolled long before the era of cell phones.) So, critics insist, the baseline assumption made in this study – that the researchers actually knew who the subjects’ close friends were – is highly suspect.

To which DrRich replies: These critics likely have fat friends, and are probably even fat themselves, and thus their complaints can be dismissed with a definitive, “Bunk!”

Moving on, critics have also complained because the kind of computer modeling used in this study is not for mere mortals to understand, and therefore amounts to a black box. And indeed, DrRich must admit that the authors’ description of their statistical maneuverings is enough to make your head spin – replete as they are with the running of numerous simulations, using differing assumptions along with a quite unembarrassed manipulation of all the variables (almost as if they were seeking the “right” combination of factors to yield the desired answer, reminiscent of the scientific techniques revealed in the emails of those global warming experts). Critics go on to complain that there are only a handful of humans who claim to understand this kind of complex computer modeling, the results of which, therefore, resemble “received knowledge,” akin to what the medieval clergy used to dole out to the unwashed masses, when most people were illiterate and there were no Bibles in the vernacular.

Bunk again, says DrRich. While the computer modeling used here is indeed unfamiliar to physicians, it is very familiar to a few theoretical economists, who have used similar modelings for years in the attempt to predict the behavior of markets within social networks. DrRich even found a formal critique of the Christakis/Fowler analysis, written by two such economists (Ethan Cohen-Cole from the Federal Reserve Bank of Boston, and Jason M. Fletcher of Yale University). And while this pair of economists, in fact, concluded that Christakis/Fowler bollixed-up their analysis of obesity to such a great extent that their conclusions are completely illegitimate, DrRich counters with this query to said economists: If you know so much about computer models, how’d your investments do during the big crash in ’08? Eh?

Finally, critics say, all the reports appearing in the popular media (which often have included provocative quotes provided by Christakis and/or Fowler themselves), seem to have exaggerated the conclusions of the study way beyond what the published study actually says. For instance, all media reports stress the general contagious nature of obesity. But when one reads the study itself, one finds that the highly-publicized ability of obesity to “spread” from friend to friend actually did not hold up for the following combinations of friends: man-woman, woman-man, and woman-woman. It only reached statistical significance when both friends were men. So while the results of this study have been mercilessly generalized, in fact only one real finding was actually suggested by this data. If either you are a woman or your friend is a woman, then your friend’s obesity is not contagious to you – even if you buy the results of this study.

To this criticism DrRich responds thusly: Having fat friends makes you fat, OK? So get over it. If you choose to believe only the details of the study, instead of its spirit (as clearly expressed by the media and by the public utterances of its authors), then go ahead and enjoy your obese female friends, and see where that gets you.

The real beauty of this study is that, since it comes from a completely unique database that will never be duplicated, the data we have is the only data we’re ever going to get. So, the quibbling of the critics aside, the very best study ever conducted or that ever will be conducted on this issue shows definitively – to the satisfaction of the people that matter – that obesity is contagious.

Since the obese are rapidly becoming the witches of the 21st century, we are obligated to do everything in our power to stop them while we can. (DrRich points out that burning witches is an evil act only if you don’t believe that witches are real. If you, supported by all the respected authorities of the day, believe that real witches are present in the community, and that they indeed are capable of producing extreme harm to innocent individuals, surreptitiously and at a great distance – kind of like the obese – then burning them is at least reasonable, if not the only responsible thing to do.)

DrRich of course is not advocating burning fat people at the stake. He is already on record as saying that committing such an act would be a crime against the environment, just based on the carbon emissions alone.

But, my goodness, why would you befriend a fat person – let alone invite one into your home for a holiday supper – when doing so will put you and your family, all the way down to the second-and-even-third-degree acquaintances in your social network, at grave risk? Until the day comes when our leaders develop the courage to do what needs to be done about the menace of obesity – perhaps gathering up all the fat people and concentrating them, say, in special camps – we must do our bit to keep them from contaminating our own social networks.

As our President says, our new healthcare reforms, to be successful, will rely utterly on the straightforward and unprejudiced application of the very best medical science available, rather than on emotions, on biased opinions, or on unsupported traditions.

Until our leaders grow the teabags to begin following their own advice, let us regular folks do what needs to be done in our own homes, especially during this very special holiday season.

May God bless you and keep you – thin.

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DrRich wishes his readers a Merry Christmas and Happy New Year – whatever their BMIs – and will return here to the CRB shortly after the holidays.

Podcast:

DrRich has written a lot on this blog about the intentional destruction of the classic doctor-patient relationship. That relationship, of course, was a fiduciary one, under which the patient was encouraged and expected to place full trust in the doctor’s sacred duty to put the patient’s own best interests above all other considerations.

Obviously, such a thing is incompatible with a healthcare system in which doctors are expected to covertly ration healthcare at the bedside. Indeed, it was the ethical tension between what the classic doctor-patient relationship required and the new duties of physicians in the real world, that led professional medical organizations to formally re-define medical ethics in 2002.

And today, of course, under these New Age medical ethics, doctors are no longer expected to place the needs of their individual patient first. Rather, they are required to make the needs of the collective – that is, social justice – their chief consideration.

When the needs of the individual and the needs of the collective coincide, of course, so much the better. But when they do not – and they frequently do not – the needs of the collective take precedence. And “the needs of the collective” are now being determined by panels of experts created under Obamacare, which are busily devising the “guidelines” for treatment that physicians must follow to the letter, or risk their careers, life savings, and freedom from incarceration.

Lest you think DrRich is making this up, allow him to remind his readers of this excerpt, from the ominously-titled book, “New Rules,” co-authored by none other than Donald Berwick MD, who has run CMS for the past 18 months:

“Today, this isolated relationship [between doctor and patient] is no longer tenable or possible. . . Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. . . The primary function of regulation in health care. . .is to constrain decentralized individualized decision making.”

Having thus terminated the classic doctor-patient relationship with extreme prejudice, the same political and medical leaders who conducted this assassination immediately realized they had to fill the void – for how can you have no such thing as the doctor-patient relationship? The solution to this problem, of course, was easy. Just as you can create a New Age medical ethics to fit modern exigencies, you can create a new doctor-patient relationship that will do the same thing.

So, what medical students are being taught today about the doctor-patient relationship has nothing to do with fiduciary responsibilities or ethical obligations. Rather, the New Age doctor-patient relationship is all about the interpersonal relationship between doctor and patient. Doctors are admonished: Be compassionate, be empathetic, be nice. And there’s nothing wrong with crying in front of your patients.

Not being an asshole, of course, has always been a useful trait for physicians. Doctors who can relate to their patients, displaying and actually feeling a certain amount of compassion and empathy, have always been more effective at communicating with their patients – and thus have been more effective physicians – than those who are arrogant, self-centered, aloof, or just plain mean*.

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*DrRich has already pointed out the following irony: many of the doctors who washed out of clinical medicine, possibly because they were too arrogant, self-centered, rigid, and/or aloof to be effective physicians, are now populating the expert panels which are writing the guidelines which will dictate the behavior of doctors who might otherwise be actually useful.
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The benefits of being a nice person are not exclusive to the medical profession. The same rules hold for anyone who makes his/her living by engaging in personal interactions with fellow humans. And so, until recent years, the medical profession categorized this fact (that doctors ought to have decent interpersonal skills) within the realm of common sense, common decency, and common knowledge – and the idea of the doctor-patient relationship meant something else entirely.

Every medical school now has formal training on the doctor-patient relationship, under which young physicians are taught to be compassionate, empathetic, and nice. To the extent that such traits can be taught – and DrRich has his doubts – there’s nothing inherently wrong with emphasizing interpersonal skills. There are, however, two problems that come to mind when emphasizing interpersonal skills becomes a substitute for emphasizing the real and true obligations of a professional.

First, teaching young doctors that a good doctor-patient relationship simply means being nice will result in newer generations of physicians having no concept of any fiduciary obligation to their individual patients. They will address the needs of the collective first, as a matter of course. (But as they withhold information on available treatments about which their patients are not to be informed, we can count on them to be extremely nice about it.)

Second, there is a growing school of thought, amongst those who are responsible for teaching this New Age doctor-patient relationship, that not only should doctors avoid stoicism at the bedside, but they also ought to openly display their emotions, so as to further reinforce their compassion, empathy, niceness, &c. By graphically displaying the deep empathy the physician has for his (or more likely, her) patients, he or she can really bond with them, and thus establish a really strong doctor-patient relationship.

And what better way to openly display one’s emotions than to cry?

Just as a general proposition, DrRich is against crying in front of patients. Certainly, there may be rare occasions when emotions rise up unexpectedly at the bedside – when a patient relates a particularly affecting personal story for instance. But in general, DrRich is convinced that doctors should not make a habit of expressing their emotions too frequently or too luxuriously to their patients.

Empathy and compassion are fine, but what sick patients really need is a doctor who can maintain some sense of composure even when things are the bleakest, some sense that, as bad as things are, this situation is not beyond the doctor’s experience. Even if the outcome is destined to be very bad, the patient deserves a doctor who acts like he or she has been there before, and who they can trust to remain at their side and help guide them through the ordeal that remains.

But DrRich is concerned that the faculty of our medical schools, who are busily training America’s Obamacare Doctors of Tomorrow, have reached the following epiphany: A particularly wonderful way to repair the failing doctor-patient relationship would be to indoctrinate young future physicians (most of whom these days, once again, are said to be women – not that there’s anything wrong with that) that crying at the bedside – indeed, openly displaying their every emotion at the bedside – is a marvelously therapeutic act. Such an open display of the doctor’s emotions conveys a powerful message to the patient, namely, “I care.”

Perhaps. But DrRich thinks crying at the bedside actually conveys two powerful messages to patients:

First Message: I empathize with you. I feel your pain.

Second Message: Your medical condition is so unbelievably dire that not even I can face it with any amount of composure. You, my friend, are well and truly screwed. I cannot imagine the agony you’re in for, without falling apart myself.  May God help you.

It is the conveyance of this latter message that, in the opinion of DrRich, ought to make most doctors on most occasions relatively circumspect about crying in front of their patients.

It is also this latter message that offers to make crying doctors a convenient tool for covert rationing.

When the doctor is reduced to tears (thus graphically demonstrating to the patient that the game’s about up; that there’s pretty much nothing, really, that’s going to change this bleak outcome; and how very sad it all is) – well! Talk about reducing your patient’s expectations!

A chief tenet of covert rationing is that patients who can be made to expect little will be satisfied with little. In most cases this is accomplished by simply coercing doctors to withhold from their patients all of their medical options. But if they can be encouraged to cry when delivering bad news, doctors can destroy patients’ expectations in a much more definitive fashion.

Furthermore, the traditional role of the doctor when a patient’s outlook is poor is to take charge of a very bad situation, and with great empathy, patience and fortitude attempt to guide the patient through that situation with as much skill and courage as possible, even if the final destination looks very bleak. If the doctor instead becomes just one more of the people who gather about the bedside crying about it, then the patient immediately perceives themselves to be abandoned and alone, placed into a position irremediably desolate, with no sense of direction, and no sense of control over their own destiny. Patients fighting illness from such a position do more than merely lose their expectations; they will also die much sooner and in greater despair than necessary.

So obviously, our modern healthcare system under Obamacare will see immediate advantages to encouraging emotional outbursts on the part of doctors. In the name of advancing empathetic physicians and fixing a broken doctor-patient relationship, we could, more easily and more often, get those folks who are in the infamous last six months of life to simply stop striving for a medical miracle – or even for non-miraculous but expensive therapies that actually exist, and that (alas!) might actually extend their survival – and thus effect the sick patient’s demise more quickly and more economically.

Certainly, now that medical schools are teaching forms of alternative medicine that in former years would have made real doctors blush, for courses on the doctor-patient relationship to encourage young doctors to let their emotions free is a good and natural fit.

Young doctors should not be taken in by such ploys. They should empathize with their patients, but remain strong, and lead their patients gently and resolutely through their medical ordeals. They should try to avoid allowing a free display of their emotions to break their patient’s spirit. Their job, instead, is to use their expertise to fortify their patient’s spirit, even in the worst of times. And above all they should not allow themselves to become the trained tools of an ultimately cynical healthcare system, that uses every ploy at its disposal to covertly ration medical care.

Podcast:

A key goal of the Central Authority, as it contemplates how best to run our healthcare system, is to do whatever it can to stifle medical progress. Medical progress usually means introducing new drugs or new medical devices, which are often very expensive in themselves, and worse, which often threaten to improve the survival of some category of patients with chronic disease. So typically, medical progress greatly multiplies the costs of healthcare, and all the Central Authority gets in return is more chronically ill people to contend with. For this reason, suppressing medical progress is a critical aspect of covert healthcare rationing.

It goes without saying that a major tactic in achieving this goal is to demonize the drug companies. If the pharmaceutical industry can be made out to be sufficiently evil, corrupt, greedy, and callous to the needs of the people, then it will become the duty of our leaders to constrain them, and in so doing, to limit their ability to develop and introduce new products. This is easily done by adding daunting new regulations, or by piling on oppressive new taxes, or by legislating “windfall profits” penalties, or by using the threat of the regulatory speed trap to threaten them with massive fines or imprisonment. It is indeed fortunate for the Central Authority that the drug companies are, in fact, not the most fastidious members of the corporate community, and that their actions and methods often suggest many fruitful avenues for demonization.

One such avenue that is particularly fruitful, since it recruits the public squarely into the camp of the prosecutorial horde, is to show how the corrupt pharmaceutical industry feeds at the trough of the American taxpayer.

A few years ago, to specifically document this sort of reprehensible behavior, the New York Times pointed us to the case of Dr. Laszlo Bito and the anti-glaucoma drug Xalatan.

In the early 1980s Dr. Bito, a researcher at Columbia University, made a key discovery about a new class of substances that could potentially treat glaucoma. His research was funded with American tax dollars through the National Institutes of Health.

Subsequently, the pharmaceutical giant Pharmacia purchased the rights to Bito’s discovery for a mere $150,000. Based on Bito’s tax-supported work, eventually Pharmacia released the anti-glaucoma eyedrop preparation Xalatan. Xalatan rapidly became a worldwide best-seller, yielding as much as $500 million in sales per year. For their part in this unalloyed success story, Columbia University has netted over $20 million in licensing fees and royalties, and Bito himself became a millionaire.

Meanwhile American glaucoma sufferers are forced to spend upwards of $50 every six weeks for a tiny vial of the drug, which costs the company only a small fraction of that amount to produce, and whose discovery the glaucoma sufferers paid for with their own tax dollars. And, as if to guild this already brazen injustice, Pharmacia makes Xalatan available in Canada, France, and most other countries around the world (where taxpayers decidedly did not support the discovery of the drug), for less than half what American patients pay for it.

It seems, the Times points out, that the American taxpayers are the only parties in this little scheme who reap no financial return on their investment. All they got were some expensive eyedrops.

And so, drug-company demonizers would have us conclude, this is a particularly egregious example of how the evil pharmaceutical industry is ripping us off. Not only are the drug companies mercilessly profiteering from sick Americans (which indeed is their openly-admitted business model), but they are also picking the pocket of every American by using our tax dollars to invent new drugs, then selling those drugs back to us at exorbitant prices. This, one could reasonably argue, is at least as sociopathic as anything the tobacco companies ever did. (The tobacco companies, in contrast, at least had the good graces to eventually stop claiming that their products were beneficial to one’s health.)

And (we in the great unwashed are all supposed to agree), if this reprehensible behavior doesn’t give our government the right to control the prices charged by drug companies, one would be hard pressed to say what does.

DrRich certainly doesn’t want to absolve the pharmaceutical industry of all responsibility for drug prices that seem obviously too high, or for the striking disparities we see in the prices they charge for their drugs between the U.S. and other countries. He has read the complex justifications, published by apologists for the pharmaceutical industry, as to why drugs in Canada cost so much less than in the U.S., and why a tablet whose actual manufacturing cost is five cents is sold to our elderly sick for five dollars. DrRich thinks that, despite all the pretty explanations the pharmaceutical industry gives for these “seeming disparities,” drug companies simply do what every other industry does – they charge the highest price the market will bear, for each market in which they participate. If they didn’t do this, they would be abrogating their fiduciary responsibilities to their shareholders.

There is much not to like about high drug prices, or the fact that people in other countries reap the benefits of American research for far lower prices than Americans do. And it is reasonable for us to seek to address these pricing issues. But as we address certain inequities in drug pricing, we should be careful that in doing so we don’t throw the baby out with the bath water. So if we’re going to alter the arrangement we have with the pharmaceutical industry, let’s be clear on how that arrangement works, and why we set it up in the first place to operate as it now does.

Consider once again the glaucoma drug Xalatan, and consider how Dr. Bito’s discovery was actually used by Pharmacia.

Bito did not discover a finished product. Instead he discovered a new concept for reducing intraocular pressure (that is, for treating glaucoma), and demonstrated that it could be effective – but the specific compound he discovered was not marketable. In fact, it was so highly irritating when applied to the eye that it was simply not suitable for human use. (DrRich does not understand why the drug companies are the evil players in this story, when Columbia University so obviously allowed research to proceed in their facilities in which irritating substances were intentionally placed into the eyes of bunnies or other cute animals.) Indeed, Bito’s new compound was so impressively unusable that, before Pharmacia bought the rights, his discovery had been offered to and rejected by a host of other drug companies as being completely infeasible.

So when Pharmacia finally agreed to pay for the rights to Bito’s patent, they took on an expensive risk that, some estimated, had less than a 5% chance of achieving success. Pharmacia assumed the difficult task of developing a brand new synthetic molecule that would have all the benefits described by Bito, but at the same time would not have the prohibitive side effects. There was no assurance at all that such a molecule could ever be developed, and the cost of searching for one would dwarf the cost of purchasing Dr. Bito’s compound in the first place.

If such a thing turned out to be feasible, then the company then would have to conduct painstaking and extraordinarily expensive human research trials, and if successful, would then have to shepherd their new compound through a time-consuming and costly regulatory gauntlet – which explains why the vast majority of promising new drugs fail to ever gain FDA approval. That their efforts were ultimately successful does not diminish the fact that, when Pharmacia agreed to invest the time, money and opportunity cost to develop Dr. Bito’s discovery, the company was committing itself to an expensive and extremely risky proposition, with no assurance of making a profit or even recouping their losses. It was, in fact, a very long shot.

The folks occupying Wall Street ought to remind themselves that the cool products they are using each day (such as the iPhones they use to organize their flash demonstrations) all came about because the profit motive – and only the profit motive – encouraged some entrepreneur to risk his/her time, treasure, and sacred honor on some new idea. And for each risk-taker who becomes a millionare or billionare, thousands of others achieve only modest success – or fail altogether. (That’s why it’s called “risk.”) But the lure of big profits drives the whole system, and accounts for American progress.

Bito’s (tax supported) idea was a promising one, but the challenge of developing that idea into a product that was useful to patients and that could be brought to market was very expensive and highly risky. Pharmacia took on that risk (all of which was borne by its shareholders, and not by taxpayers) only after difficult, internal corporate soul-searching. If not for the prospect of making enormous profits if this risk worked out, the company (like several other drug companies did in this particular instance) certainly would have walked away.

Before 1980, it is likely none of this would have happened. The Bayh-Dole Act of 1980 was passed expressly to encourage the further development of federally financed, university-based basic research. Until then, a large proportion of basic university research was never “translated” into useful medical products. Such translation of basic research was recognized by Congress to benefit society not only by advancing the practice of medicine, but also by stimulating the overall economy. So industry was actively encouraged to take on the risk of developing promising ideas that came out of federally-funded research. And the profit that greeted successful enterprises was designed to be the one thing that would lure industry into taking that risk.

So when the Times “discovers” a company “profiteering” from work done with tax dollars, it should not be a revelation, nor should it be an unmistakable sign that the company is inherently evil or dishonest. Nor does the company’s activity in this regard give us a justification to arbitrarily restrict its profits. Rather, that’s simply the deal we taxpayers (through our elected officials) have made with the drug industry. We made this deal because we felt it would benefit American society, the American economy, American patients, and quite probably, us as individuals. Of course, if we want to change that deal now, it is within our rights to do so.

Without Bayh-Dole, perhaps patients with glaucoma would still be getting surgical therapy and wearing those coke-bottle eyeglass lenses instead of just using eyedrops. And if we wish to allow the Central Authority to put the brakes on such medical advances (ostensibly to prevent unseemly profiteering, but actually to stifle medical progress), we certainly can. It’s how covert rationing works.

But we shouldn’t vilify the drug companies for taking us up on the deal we offered them, back when we were thinking more clearly.

Podcast:

DrRich does not like to pick on the New York Times.

No, really. DrRich does not like to pick on the New York Times, because he receives two paychecks each month from the New York Times*. This fact (which has been disclosed on this blog since its inception in 2007) constitutes a clear conflict of interest, at least when it comes to writing blog posts which might criticize or satirize or mock articles that appear in that venerable publication, from which he receives a not insubstantial proportion of his livelihood.

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*DrRich holds two positions at About.com, which is a New York Times Company. He has manged About.com’s Heart Health Center for 11 years, and also serves on About.com’s Medical Review Board.
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Yet, regular readers will know that the New York Times has served as a regular source of material for DrRich here at the CRB, and little of what he has written in response to that material has been supportive of it. Indeed, the opposite is true.

DrRich considers it his duty to respond to the New York Times whenever it publishes an article that advances the covert rationing of American healthcare, which (through no fault of his), it does frequently. The New York Times serves as a chief voice of Progressive America, and the Progressive takeover of the healthcare system has become, since this blog was first begun, the chief driver of covert rationing. So, conflicts of interest to the contrary notwithstanding, DrRich submits to his readers that he has acted responsibly and honorably despite his unfortunate financial conflicts.

But still, he does not like to pick on the New York Times.

It is unfortunate for DrRich, then, that for the second time this week he is compelled to do so. And this time, as it happens, the subject matter has to do with conflicts of interest (a subject about which, as he has just disclosed once again, DrRich knows something).

Today, the Times writes that experts are beginning to worry that the GOD Panels (Government Operatives Deliberating) now working to devise the clinical guidelines under which American doctors will be strictly compelled, under penalty of the law, to decide which patients will get what, when and how, are tainted by members who have had ties to (gasp!) industry.

When the GOD Panels were first set up, not very long ago, it was still considered acceptable for some members to have industry ties as long as they fully disclosed those ties, and recused themselves from voting on matters specifically related to their industry work. Having at least some members with industry ties was deemed essentially unavoidable, because it was thought that deep subject-matter expertise would be desirable on these panels. Since most clinical research in America is paid for by industry, it is difficult to have deep expertise without having had at least some contact with industry.

But as the Times indicates, modern medical ethics has now advanced well past this kind of primitive thinking. Nobody with any industry ties has any business being on a panel with such overwhelming authority over the practice of American medicine.

David J. Rothman, president of the Institute on Medicine as a Profession, tells the Times, “Consciously or not, they may well be making decisions that fit their funders, their payers and not the patient’s best interests. If you want the public to really believe in the guidelines, why not have a committee that is conflict-free?”

And the ubiquitous Dr. Steven Nissen of the Cleveland Clinic (a person DrRich numbers among those individuals who, by their public words and deeds, he speculates may be auditioning for the really important GOD Panels) says, “Recusing, disclosing — the reason it doesn’t work is the process involves give-and-take. Even if you don’t make a formal vote, you can still have a huge influence over what happens in the process.”

And so, while the Times does not come out and say so, it seems as if a purge of the GOD panelists may be already afoot. If not an actual purge, then at least the “conflicted” panel members are being sent a clear message, well before they take any final action. And at the very least, Ms. Sebelius is being given the cover she needs to select the people she really wants for the truly important GOD Panels which are being constructed for Obamacare.

All of this is pretty clear, and DrRich has great confidence that his readers can figure it out for themselves.

What DrRich really hopes to accomplish here is to note for posterity the great paradigm shift that has occurred in just the last two or three years, regarding the appropriate relationship between physicians and industry.

Until very recently, the American public, doctors, industry, and medical ethicists thought about that relationship in a certain way, which DrRich will call Theory A:

Theory A:

-  Medical progress is Good, and benefits mankind.
-  Industry is responsible for a high proportion of medical progress.
-  Industry-driven progress requires the active participation of physicians.
-  Therefore, a well-managed cooperation between industry and physicians is beneficial to mankind, and ought to be encouraged.

If you subscribe to Theory A you believe that, because well-managed physician-industry relationships benefit mankind, these relationships are good. So, fundamentally, it’s the management of these relationships which is at issue. These beneficial relationships produce unavoidable conflicts of interest, which we must manage by strictly limiting their extent, and fully disclosing the ones that are left.

So traditionally, the debate about conflicts of interest have been about where to draw the necessary limits.

What today’s New York Times article points out is that Theory A is no longer operative. The new thinking begins with the proposition that no amount of conflict of interest is acceptable, and ALL physician-industry ties should be prohibited. One of the most prominent advocates of this new thinking is Jerome Kassirer, former editor of the New England Journal of Medicine, who says, “The ideal handling of conflicts of interest is not to have them at all.” For these voices, Theory A simply does not apply. Rather, they subscribe to Theory B:

Theory B:

-    The greed of medical industry creates excessive costs, and produces far more harm to society than good.
-    Physician-industry alliances strengthen industry, and increase the harm.
-    Therefore, crippling these unholy alliances is critical to the interests of society.

Underlying Theory B, of course, is the largely unspoken and unacknowledged, but nonetheless fully-embraced, proposition that medical progress is not Good after all, but is the very thing that is driving up our healthcare costs, and so it must be stifled.

A corollary of Theory B is that not only is the Central Authority the only entity which is strong enough to cripple these unholy alliances between physicians and industry, but it is the duty of the Central Authority to do so.

Proponents of Theory B, noting, not incorrectly, that medical industry is chiefly concerned with profits rather than the public good, conclude (in a manner compatible with Progressive if not classical logic) that therefore industry will always behave in ways that are counter to the interests of society.  While many proponents of Theory B will agree that industry provides at least some benefits, they are convinced that these benefits are far outweighed by the harm they produce to the collective. Therefore, Theory B proposes to stifle, if not cripple, medical industry. And a very useful strategy for achieving this goal is to de-legitimize any practical relationships whatsoever between medical industry and physicians.

Proponents of Theory B rarely say what their real goal is. To come out and say that their goal is to cripple the companies responsible for producing medical progress would not be expedient. So most of them still give lip service to Theory A. One must discern their real motives from their behavior.

Much of that behavior, in practical terms, has to do with controlling the flow of information. Let industry develop whatever it wants (perhaps), but don’t let profit-drunk industry – or its greedy physician spokespersons – instruct doctors and patients on who ought to use industry’s products, or when and how. That kind of information can only be managed by unbiased sources.

This is the very thinking that produces the impetus for GOD Panels in the first place. Only experts who are free of industry ties and who answer only to our beneficent, unbiased, completely objective government can say which products of industry are good and bad, and can manage the flow of information about them. Information coming from anywhere else is to be regarded as being charged with bias and greed, and should be ignored, or even suppressed by whatever means are necessary.

To any reader who believes that our government is or can ever be an unbiased and honest broker, or that government officials (or GOD panelists) can cancel their own human natures when they put on a government name tag, DrRich can only wish upon you the grace of God (the old fashioned one). You’ll be needing it. To the rest of us, it is obvious that the government is desperately biased when it comes to medical progress in general, and in particular when it comes to establishing “guidelines” for the use of expensive drugs and medical devices.

For Theory B to have become the operative paradigm in America, as the New York Times today suggests it has, will assure the Central Authority that it is free to seed its GOD Panels only with members whose bias runs in their direction.

But under Theory B there is no government bias. There is only industry bias. And when we purge the GOD Panels of all industry bias, by definition we will have created perfect objectivity.

And this is why DrRich feels so comfortable continuing to write this blog despite his obvious financial conflict of interest in favor of the Times. For a conflict of interest in the direction of the Progressive agenda is no conflict at all.