When Bad Advice Is the Best Advice

Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.

Not long ago, as part of my hospital duties, I cared for a man who could no longer swallow. This dysphagia was his only medical complaint, one that had sneaked up on him over the course of a month. He simply couldn’t find the muscular strength to propel food and liquid down to his stomach.

After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.
While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life — small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but the best we could offer.
On rounds the morning after he received a feeding tube, I stopped by to see how he was doing — checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.
I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical or a social question. It was his wife who replied — angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business.
She looked toward me for support — I was the physician, after all — and I found myself in a common medical quandary.
Was it my duty to tell this patient what to do or, instead, to give him the medical information he needed to make up his mind?
Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient’s preferences.
Should a middle-age woman with mildly elevated cholesterol take a statin, for example? That depends on whether she thinks the pill’s benefits outweigh its burdens, burdens that only she can judge: costs, possible side effects and the inconvenience of taking medications.
Should an elderly man have knee-replacement surgery? That depends on how much he is suffering, how much he cares about the risk of surgical complications and how willing he is to undergo lengthy and painful rehabilitation.
According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options.
So going by the book, I should have informed my patient about the pros and cons of tobacco. But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.
I advised him to smoke.
“You two obviously love each other very much,” I said. Then I turned to his wife.
“I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker,” I continued, as I recall. “But those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax. What matters is that you two stick together, because these next few months are going to be really difficult.”
I reminded them that the cancer wasn’t curable, that we were hoping to improve his quality of life, and that the best way to do that was to spend quality time with the people he loved.
Every situation is different, of course. But my duty as a physician is to improve my patients’ lives. And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do.
Even if it means encouraging them to smoke.
To read the original article at nytimes.com, CLICK HERE.

Feeling Conflicted about Greed

With jobs disappearing faster than a major league fastball, the public is understandably irate at the damage that greed has wrought upon our economy. Financiers destroy their companies, and our retirement portfolios, and then complain when their bonuses are less than 7 figures.
The greedy behavior in recent headlines has not been limited to Wall Street. Last fall, for example, Congress uncovered the shocking details of Dr. Charles Nemeroff, Chair of psychiatry at Emory University, who had made almost $3 million in consulting fees from the same drug companies whose products he was prescribing. More disturbingly, he was responsible for evaluating these same drugs in federally funded research trials. Then in November, we learned that renowned Harvard psychiatrist, Joseph Biederman, had received hundreds of thousands of dollars from Johnson & Johnson, a company which made medications that, not by coincidence, treated the same childhood psychiatric illnesses that Biederman had become famous for publicizing to doctors.
With all of these disturbing stories, it is natural to attribute our current economic problems to excesses of greed.
Greed is indeed a prominent theme in many recent headlines, but it doesn’t explain what has been happening. Greed is a reliable constant in human affairs. Attributing the current situation to greed is like attributing someone’s headache to the fact that they have a brain. The real explanation lies not with greed, but with our failure to deal with conflicts of interest.
Conflicts of interest have played a central role in many of the disasters that have befallen our economy in recent decades. Enron and other corporate debacles a decade ago were aided and abetted by accounting firms that were providing consulting services to the same companies they were auditing, creating a situation in which the right-hand was expected to raise the alarm about financial practices being suggested or condoned by the left hand. The dot-com crisis was similarly aided by stock analysts who provided buy recommendations for companies whose stock their firms were underwriting. And now in the most recent debacle, it has emerged that credit rating agencies, entrusted to identify risky finances, were aggressively drumming up business from the same lenders whose credit they were rating.
As highlighted by publicity over the payoffs to psychiatrists, conflicts of interest have also contributed significantly to another less acute but equally serious problem plaguing our economy: the ever-intensifying problem of skyrocketing health care expenditures. Despite numerous calls for change, pharmaceutical companies continue to shower physicians with gifts, and an increasing proportion of medical school faculty obtain an increasingly large proportion of their income from industry. (Disclosure: I am an academic physician, but I have made a practice of staying independent from industry funding. That independence has come easily, given that most companies have no interest in a primary care physician who studies decision making and ethics!) As a result, the newest and most expensive interventions are enthusiastically embraced by the medical community, often before their safety and effectiveness have been firmly established.
In the face of economic turmoil, it is tempting to look for greedy villains. By the time there are villains to punish, however, it’s usually too late to fix the problem. Shooting the fox won’t restore chickens to the hen house. Instead, we need regulations to reign in the pernicious effects of conflicts of interest.
How can we do this? Beyond calls to punish perpetrators, the most common response is to call for greater disclosure of conflicts. Medical journals and medical schools, for example, have largely tried to address conflicts of interest by requiring physicians to disclose their outside income. However, disclosures are not a solution. For starters, people often don’t report their conflicts. Nemeroff famously failed to report the majority of his $3 million in consulting fees. More importantly, disclosure can cause outsiders to drop their guard – when a physician readily admits working with a drug company, other people mistakenly assume that he must therefore be being forthright about his research results.
The only way to reduce the effects of conflicts of interest is to reduce the conflicts themselves. Auditors and bond raters shouldn’t be hired by, or provide other services to, the companies they are rating. Stock analysts shouldn’t be allowed to provide buy recommendations on stocks their firm underwrite. Physicians shouldn’t be allowed to accept gifts from pharmaceutical companies.
As Obama continues to implement policies meant to avert future economic disasters, it will be essential for his administration to take a hard look at regulating the conflicts of interest that pervade our economy. Only by doing so can we get our economy back on track, and prevent another precipitous derailment.
Note: I am joined in today’s post by George Loewenstein, Herbert A. Simon Professor of Economics and Psychology at Carnegie Mellon University.
To read more of my blogs, and to learn more about my new book, Free Market Madness, check out my personal website: https://www.peterubel.com
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Market rationality and hormonal logic

Studying economics in college at the dawn of the Reagan presidency, I learned about the wonders of free-markets. The invisible hand of the market, I read, guarantees that thousands upon thousands of people–each with unique desires, abilities and values–mesh together, thereby able to achieve the balance of work and leisure, and of material and spiritual wealth, that they strive for in their lives.
In the long run, I was told, market imperfections correct themselves- eventually risky speculation is punished, foolish commercial enterprises fail, and the stock market sets the right price for company shares.
Unfortunately, to paraphrase John Maynard Keynes, in the long run we’re all dead, and some of us don’t want to wait that long for the market to correct itself.
Belief in free-markets has long been tied to unjustified faith in human rationality. But human nature is a surprising mixture of rationality and irrationality, and policies that don’t recognize the fullness of human nature are doomed to fail.
Consider the “rational” lenders who become so enthusiastic about risky mortgages. At the same time that the mathematical parts of their brains were calculating the risks of sub prime mortgages, more primitive parts of their brains were at work. Behavioral scientists, for instance, have discovered that testosterone fuels risky decision making. What happens when you mix testosterone with a young Wall Street investment banker, striving for dominance in his field and pursuing a huge year-end bonus? Is it any surprise that this male dominated industry made such poor decisions?
To make matters worse, when men win at things, like basketball games or risky investments, their testosterone levels rise even further. Not hard to imagine a vicious cycle here, a culture of risk fueled in part by hormones and reinforced when early risks are rewarded.
People can’t stop being human. We humans can’t ignore that our advanced centers of reasoning lie on top of primitive brain structures, ones we share with reptiles and chimpanzees.
To reduce the chance of future economic crises, we need sensible and careful government regulations that temper our more animal instincts. If such regulations had been in place in the last decade, we might have dissuaded more people from taking out unnecessarily risky mortgages, and we might have avoided our current economic crisis.
To read more of my blogs, and to learn more about my new book, Free Market Madness, check out my personal website: https://www.peterubel.com
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