Politics of N of 1 pseudoscience

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Medicine’s ethics and basis in science hang by a thread at times. At least in the US of A. I will present a few examples and illustrate them with correlates from other fields in which decisions with wide effects are sometimes made by the whim of one person. And that’s not just the declaring of war or whatever we call it these days.Start with an anecdote of mine from the mid-1970s or so. I somehow got involved in a dispute with the staff of then Gov. Jerry Brown over his proposal to de-license medical practice. He sent out early holistic medicine vibes and viewed health and medicine as fields open to anyone to practice by simply hanging out a shingle. I asked to meet with my state assemblyman and complained about the situation. I stated that physicians determined what medical practice is. He smiled benevolently and broke the news. “No, doc, we (in state government) do.“

I immediately recognized what he was saying. All licensure is granted by the state, and all regulations and laws referring to each occupation’s license are determined essentially by a majority vote and a governor’s signature. All those heroes in the history of medicine and science not withstanding. It was an awakening.

Jerry Brown’s vision did not materialize and he came to recognize holistic and alternative medicines as so much goofy stuff and quackery, as he later confided at a fund-raiser (yes, I went.)

In the California Assembly, all sessions and committee assignments are determined by one person – the speaker. I recall when Jess Unruh and Willie Brown held Assembly members hostage at the Capitol until certain legislation was passed. Nothing anyone else could do about it.

Shift to the Reagan Administration. Reagan was bound to a religious view of life. He put out an administrative edict for all agencies receiving federal funds, that malformed babies are life, must be treated as normal, including the max in pediatric intensive care. Anencephalics previously left to expire had to be kept alive by extraordinary means, through the edict of one person. Not only that, but signs had to be posted in all nurseries announcing the edict, and that there would be penalties for anyone who observed a violation and did not report it. I flashed back to the Germany of WW II, the Gestapo, and to the then USSR which suffered under similar policies and reporting.

So it was nothing new when George W. Bush came out last week with yet another edict for institutions receiving federal funds. With a detailed description of stages of fertilization of the ovum and against any contraception that interrupts implantation. A president again determining a life/death issue formerly left to the individual as a basic freedom.

This one-person, massive effect phenomenon occurred again last week when House Speaker Pelosi adjourned the House of Representatives before a discussion or vote could occur on an energy bill – despite the bipartisan formation of one such bill. Her decision for public consumption was to save the environment by preventing more oil drilling, but few could miss the political reality – no solution under Bush; wait until after the November election. Low income public be damned.

A similarly close vote occurred with the override of Bush’s veto of the Medicare bill – a narrow override, which also prevented a ten percent cut in Medicare physician fees. Close, and a message should be sent to HHS to clean up the fraud in Medicare before more fee cuts. But who is listening to that rational approach?

In California, Governor Schwartzenegger announced a cut or delay in minimum wage and other cuts for people who could least afford them, while political fat cats on state boards and commissions collect six-figure salaries for messing up the state workings with unnecessary smog controls, boutique fuel requirements, additives that don’t work, prohibited nuclear reactors, and so on. While MediCal fees are lowered every few years to the point of less than the cost of rent and utilities.

And lastly, the courts. Roe vs. Wade and progeny, eminent domain, gun control and others all being determined by a 5:4 vote by a widely split court, one justice making the difference..

Did I say lastly? You have obviously been waiting for modern scientific medicine’s first two legal shots taken from Senator Tom Harkin with his National Center for CAM, and his commercial twin, Senator Hatch and his 1994 DSHEA act. Each of these was created by one individual expressing personal fantasy and self-interest with political hits on medicine. Each has lasted almost a generation.

There is a serious lesson to be learned here that many of us do not see. In clamoring for a national health care scheme or a single payer plan with extraordinary power to pay for pseudoscience and quackery, we may be asking for a medical system run for and by political schemers and seekers with power to install their strange ideas, immune from reason or opposing majorities. As bad as HMOs and insurance companies appear to be, they pale in comparison with the power of the state and the potential for one person with personal or political urges and fantasies to do with medicine as one pleases.

Posted in: Medical Ethics, Politics and Regulation, Science and Medicine

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16 thoughts on “Politics of N of 1 pseudoscience

  1. nixar says:

    Oh the big bad government!
    Hey Wallace, here’s an idea; how about you apply the scientific method? Why not go have a look at a country with some sort of universal healthcare. It’s not that hard: that’s basically any developped country except the US.
    And how do they handle this? Not nearly as bad as you claim. Here in France the system covers homeopathy and not much else as far as crap-based medicine is concerned. It’s infuriating, but at least it’s cheap crap.
    Well guess what, there are many private insurers in the US that cover crap-based crap. I can’t be fscked to look it back up, but I believe I read about it on the NESS board or blog. And you know why they cover it? Because it’s cheap, and it’s one item they can advertise on. Covering cancer is expensive, so they’ll boot cancer patients as soon as they can, under BS pretenses. Universal healthcare doesn’t do that. So what if it wastes .1% on sugar granulates? At least it doesn’t blow 30% on prime time TV ads like the private sector in the US (oh yeah, here’s another difference between the US and the sane world: drug ads are banned from TV)
    You say you want science? So look at the goddamn numbers. Infant mortality rates? US sucks. Longevity? US sucks. Cost? US sucks. Rate of preventable deaths? US dead fscking last.
    Oh yeah now I realize you’re the guy who posted about the Iraqi war dead “scandal”. Drink the kool-aid all you want; but don’t drape yourself in “science”: the facts, they’re not on your side.

  2. Nixar – while Wally prefaced this entry with a notice that it will be political, it was not it any way a broader discussion of the strengths and weakness of a single-payer system. Wally did not even touch upon any of the points you raised.

    The entry clearly had one theme – in the US individual politicians can work the system to have a disproportionate effect on policy. Historically there are numerous examples of this, some of which specifically involve introducing pseudoscience into medicine. This needs to be considered when calculating the net effect of going to a single payer system.

    My personal view is that, while Wally has a point, I don’t think in the end it really matters. Regardless of the system, we will be fighting the infiltration of pseudoscience and anti-science into medicine. We have to fight it with the various federal regulatory agencies, with all 50 states, with hospitals, insurance companies, and universities.

    Regardless of the system – we need to fight against politicians deciding for themselves what is science – against the scientific mainstream. With a single payer system both the losses and victories would be greater – sort of winner take all. Whether or not this is better or worse is a matter of opinion.

    Finally (although this is a separate point) I would caution against comparisons to other countries – there are too many variables to make straightforward conclusions.

  3. Fifi says:

    Or not. Clearly medicine being a private industry with powerful lobbying by those that can afford it like influential insurance companies, CAM promoters and supplement manufacturers, and pharmaceutical companies who have more power than citizens isn’t working so well in the US either. America’s ongoing issues with corporate welfare and minimal social services for citizens is a problem within US politics and social systems – and the Republican “free market” agenda that’s been promoted by the same people since Reagan. It’s certainly not grounds to indict universal healthcare. Universal healthcare in Canada doesn’t pay for CAM and certainly in most countries is no more (and usually much less) prone to influence from corporate pressure than in the US (where corporations often have more rights and more government handouts than citizens do).

  4. David Gorski says:

    Two points:

    1. I must disagree with Dr. Sampson’s apparent underlying premise that if we adopt universal healthcare there will be a greater infiltration of pseudoscientific nonsense into medicine. This is an underlying assumption that does not appear to be born out by an examination of other nations with universal health coverage. Also, businesses (such as health insurers) respond to their customer base as politicians respond to their constituencies. If enough of the customer base wants woo to be covered, then woo will be covered. Then there’s the traditional U.S. love of individual freedom, which is harnessed in the counterproductive “health freedom” movement, which is in practice means the freedom to practice quackery without any pesky government regulation or interference. (One notes, for example, that Dan Burton and Ron Paul, two major Congressional boosters of the “health freedom” movement, aren’t exactly known for their liberal, big-government tendencies.) In any case, the coverage of woo by insurance already happening. Many plans already cover acupuncture, and an increasing number cover naturopathy. Some of this is due to new state laws mandating it; some of it is happening without any interference by the state. In other words, less government involvement in health care is arguably as likely as more government involvement to result in a proliferation of quackery made available to the public.

    The bottom line is: If people didn’t want this stuff, then it wouldn’t be a problem in our current system or under a universal health care system. But people do want the stuff; so it is a problem now and would likely still be a problem under any sort of universal health care system. The real problem is educating people about the scientific method and how to recognize implausible health claims.

    2. I really wish Wally had refrained from making a gratuitous reference to the Nazis and the USSR. (Indeed, I groaned when I read that sentence.) It added nothing to his argument and came perilously close to an argumentum ad Nazium. The reference was incongruous, too, given that it was made in the context of a discussion of a Reagan-era mandate to keep anencephalic infants alive. After all, the Nazis weren’t known for keeping deformed babies alive, but rather for their T4 euthanasia program, which involved the involuntary euthanasia of “life unworthy of life.” They would not likely to have supported any such measure. I realize that Wally was criticizing bureaucratic political mandates dictated to health care providers and not necessarily any one specific mandate, but he could not have picked a worse example to pull out the “Nazi card” for. The overall effect was truly jarring and not in a good way.

  5. Fifi says:

    The nazi=Jerry Brown comment just made me want to listen to the Dead Kennedys’ California Uber Alles :-)

  6. mrgeek says:

    First, whether in government or the “free market” (whatever that actually is), without oversight, all sorts of nefarious and/or incompetent activity is inevitable.

    Second, perhaps it is reasonable to look on alternative medicine as a tax in the context of a single payer system. Assuming a single payer system includes meaningful oversight, how much of a tax might we have to face? Surely it will be less than the 20+% tax we pay now to accountants deciding who should get treated and who shouldn’t, and which treatments will get paid for and which won’t, based not on scientifically established medical need, but on how to maximize profits for the insurance companies. Sounds like a bargain to me.

  7. David Gorski says:

    Actually, in all fairness, Wally didn’t liken Jerry Brown to the Nazis. If anything, he likened the Reagan Administration to Nazis and Soviets…

    But California Über Alles is an awesome song.

  8. Fifi says:

    Dr Gorski – You’re entirely correct and I realized my mistake after the fact but since you’ve opened the door to music geekdom… The appropriate Dead Kennedys Reagan reference would have been to Emperor Ronald Reagan (We’ve Got A Bigger Problem Now, which also has the refrain “California Uber Alles).

  9. Dr. Gorski, “The bottom line is: If people didn’t want this stuff, then it wouldn’t be a problem in our current system or under a universal health care system. But people do want the stuff; so it is a problem now and would likely still be a problem under any sort of universal health care system. The real problem is educating people about the scientific method and how to recognize implausible health claims.”

    Some may be covered because customers request it, but where laws mandate such coverage as in Vermont where I live, I’ll bet that they were passed because industry lobbying groups got politicians do do it with out the public even knowing, just like DSHEA.

    It would be great to see a real effort made to educate the public about medicine, an effort to teach people the facts about history and the way people lived and live who don’t have access to scientific medicine, but I don’t see that happening anytime soon. Heck how many people erroneously believe that shamans, traditional healers and their own grandmothers actually cured serious diseases? Until the public is educated and knows the facts, it can’t recognize “implausible health claims”, especially when the Unscientific Medical Industry spends huge sums deceiving them, marketing their goods and services and feeding them erroneous ideas about all those miraculous “natural remedies” shamans, healers and grandmothers used.

  10. nixar says:

    Steve: “it was not it any way a broader discussion of the strengths and weakness of a single-payer system. ”

    The line of argument sounds very much like something Al Franken said, “Republican campaign by claiming government doesn’t work, and procede to promptly prove it as soon as they’re elected.”
    Americans don’t trust their government. There are many reasons why they shouldn’t. Chief among them, IMO: it’s corrupted by moneyed interests.
    And that’s particularly true of healthcare, where powerful insurance companies lobby constantly in congress, pharmaceutical companies buy the bulk of TV and other media ads, which makes said media obviously reluctant to oppose them.
    Is it different in other countries? You bet it is. And you should figure out why. Let me venture an analysis. Universal health care means that the system is a lobby in itself, and it is more powerful than all the other ones. Unlike Medicare and Medicaid which are used by a minority of the population, the quality and cost of the system are direct campaign issues. Slashing benefits or insufficient care leads to people complaining and voting in protest. Raising premiums too. Pfizer or Aventis may try to buy a member of parliament lunch, but he will probably think twice before pissing off his constituents.
    There is nothing better about our politicians. On most issues they’re probably just as corruptable as the US ones — slightly less, probably, because of more stringent campaign finance regulations, but not that much. After all we elected such fscktarded hacks as Sarkozy or Berlusconi. But even those gigantic right wing douches couldn’t touch their respective health care systems, although they do try from time to time. Doctors, nurses and patients wouldn’t let them; not insurance company spreadsheet-pushers.

  11. weing says:

    I was personally hoping Congress wouldn’t override Bush’s veto. I’d love to see the 10% cut in Medicare payments. It wouldn’t take long for doctors to realize they couldn’t pay their rent, utilities, and staff and would refuse to see Medicare patients. No, what we have instead is a slow bleeding of primary care with a smaller cut due to inflation. The AMA and congressmen can congratulate themselves on saving medical care.

  12. Jules says:

    I just thought that this ( would be a timely addition to the discussion.

    The Question, I guess, is this: Do we say, “We’ll give you whatever you want as long as you pay for it” or “We’ll tell you what you want but we’ll cover the cost”? Because neither situation seems particularly fair to me, though the first appeals more to my sense of market economics and all that fun stuff.

    The latter, of course, assumes that nationalized health care ever gets farther than the holding cell of the House.

  13. overshoot says:

    I stated that physicians determined what medical practice is. He smiled benevolently and broke the news. “No, doc, we (in state government) do.“

    And I would reply with a paraphrase from another politician: “If the state government calls a tail a leg, how many legs does a dog have?”

  14. mckenzievmd says:

    This piece takes an unavoidable political given (politicians have influence over policy even when they are acting irrationally) and draws an unsubstantiated conclusion (government involvement in paying for healthcare is worse than the alternative, especially vis a vis CAM). This is ultimately just the expression of an underlying political intuition, not a substantive argument.

    I wholeheartedly agree with many of the examples of political nonsense, including the DSHEA. But simple reference to history (try Snake Oil Science, by R. Barker Bausell as previously recommended here) shows how poorly the lack of government involvement in healthcare works. And while comparisons can be misleading, the experience with government healthcare systems in other coutnries is data to be considered.

    In any case, Steven Novella is right in poitning out that the piece was not “a broader discussion of the strengths and weakness of a single-payer system.” It was more like a political advertisement against such a system. List some examples of how politicians have messed up medicine and then imply that this somehow makes the concept self-evidently wrong. A b roader discussion would probably be more useful.

  15. wertys says:

    Australia has had a nationalized health insurance system now for about 25 years, and it has definitely not led to an increase in woo being covered. If anything it has made medical professionals fight like junkyard dogs for funding for treatments which (by and large) are well supported by science. There has certainly not been an inilfration like the NHS in the UK although this was largely predicted. It has been the Australian experience that even a Federal Health Minister cannot achieve more than a couple of pet projects due to the systematic conflict between the clinicians, bureaucrats and politicians which is enshrined in the system. Regrettably the private insurers in Australia, being voluntary organizations which are nothing like HMOs (in Australia BTW, HMO stands for Hospital Medical Officer, ie a junior doc) have much lower thresholds for woo as they have to attract young and fit customers to offset their older ones with higher claims

  16. Fifi says:

    wertys – “Regrettably the private insurers in Australia, being voluntary organizations have much lower thresholds for woo as they have to attract young and fit customers to offset their older ones with higher claims”

    It’s very much the same situation in Canada – private health insurance (work insurance) is essentially dental, eyes, psychotherapy, massage and some woo (but not all). I know of no one who actually buys private health insurance, it’s a job perk/expense (so it’s companies/corporations that are buying the insurance plans). All these things can be written off on taxes as well (as can any private medical expenses).

    No doubt it doesn’t help that so many in the upper echelons of British society believe in woo (like the Queen and Prince Charles, Tony Blair and his wife who are into extreme woo, etc…it should be noted that Tony Blair seems equally entranced by the ‘magic’ of fame/celebrity and to be a rube and easy mark for various kinds of con men). To me, this makes them incompetent to rule since it means they can’t tell fact from fiction. (Though this is a common feature in US presidents too who dislike all that pesky reality based thinking, consult astrologers and so on.) Personally I don’t think it’s that surprising that people who rise to (or are born into) positions they haven’t really earned (and aren’t really capable of filling on some levels) believe in magic and their own special place in the cosmic order (particularly ones living in a cocoon of nice fuzzy spin and minions chosen for their ability to grovel and flatter to keep that cocoon cozy and safe).

    You’ve got to wonder if Blair was just out to destroy the British Labor Party.

    An interesting article from The Guardian last year about it…

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