Home > Critical Thinking, Culture & Media, Government, Science & Technology > An Exercise in Fatal Futility: Trying to Objectify the Subjective

An Exercise in Fatal Futility: Trying to Objectify the Subjective

Earlier in October, in a demonstration of my statistical insanity, I attended a (and presented at) conference of statisticians conferring as one might expect on statistics.  The conference revolved around one particular software package the identity of which is irrelevant to this post (but if you really want to know, it’s SAS).  However, one presentation I attended actually spilled over into realms of which I suspect the author was aware, but did not explicitly state at the time.  An exposition of the topic is relevant to the current political landscape, so I thought I would address the gorilla in the room with the following commentary and observations since it is an interface of the kind addressed by this blog.

The paper was entitled “Comparative Effectiveness Analysis and Statistical Methodology” and if that doesn’t put you to sleep, be assured that what follows will, or should, wake you up.  Let me give you the relevant portions of the paper summary as a framework for my analysis (with emphases added):

The purpose of comparative effectiveness analysis is ordinarily defined as a means to compare the benefits of drug A versus drug B. However, particularly in relation to cancer drugs, there is only drug A. Therefore, comparative effectiveness analysis tends to compare drug A to a quality adjusted threshold value, with a frequent conclusion that the cost of the drug is not worth the additional life. Ordinarily, a societal perspective is used to deny the drugs, since the additional life may be worth the drug cost for the patient. The British organization, the National Institute for Clinical Excellence (NICE) has denied many cancer drugs to their patients. The Centers for Medicaid and Medicare want to initiate a similar process, denying treatments that exceed a quality adjusted price of $50,000. There are similar provisions in the Healthcare Reform Act. With the emphasis upon medications, medical procedures are not as subject to this comparative effectiveness scrutiny; procedures can frequently exceed the cost of medication treatments. However, each medication is considered separately; no analysis examines the total contribution of the treatment to the overall cost of healthcare.

Let’s parse this out in plainer language.  There is a statistical method called comparative effectiveness analysis that is valid for the comparison of effectiveness of two drugs, but which is less appropriate in instances where there is only one drug for a condition and so there is no objective data with which to compare the drug under consideration.  What the bean counters are comparing to instead is this “quality adjusted threshold value” for the cost of the medicine, and the “quality” being used to adjust this threshold value is a “quality of life” metric rigidly defined in terms of the ability to function independently (i.e., how well can the patient take care of him/herself) regardless of a multiplicity of other possible considerations from the patient’s point of view.

It is this quality of life metric that is so troubling, because what is being attempted is the transformation of a highly subjective concept into an objective measure and to do so without regard to the multivariate aspects of the patient.  This transformation leaves medicine behind and spills over into the realms of ethics and theology, realms in which a materialist accountants are quite uncomfortable at best and to which they are often hostile.

This process has already been implemented in Great Britain, has already been implemented in some states in this country, and is a part of the Obamacare package despite what the Democrats may have told you (actually, they did say we had to pass the bill to see what was in the bill, so I guess we shouldn’t be too surprised, right?).  The practical outcome of this implementation is hideous in its impact on life:

The National Health Service in Britain has been using comparative effectiveness analysis for quite some time. NICE stands for the National Institute for Health and Clinical Excellence. This organization has defined an upper limit on treatment costs, and if the cost exceeds this pre-set limit, then the treatment is denied. It does not matter if the drug is effective or not. That means that there are many beneficial drugs that are simply not available to patients in Britain.  Fully 25% of cancer patients are denied effective chemotherapy medications.

That’s right, rationing of treatments based on criteria that have nothing to do with the ability of the drug to cure the disease or alleviate any symptoms.  And don’t think it can’t come here.  As I posted awhile ago, it already has, as the current authors note:

Oregon has become notorious in its Medicaid benefit, denying cancer drugs to patients, but making the same patients aware that assisted suicide is available. Oregon will not make available drugs that can prolong a patient’s life; it will make available a drug to end it (which will then save additional medical costs). Currently, pharmaceutical companies have been subsidizing Oregon’s Medicaid by providing these drugs to patients who have been denied by Medicaid. It has been suggested that euthanasia is cheaper than end of life care, and more cost-effective than treating many patients with terminal illnesses. Just recently, the Food and Drug Administration has considered retracting approval of a chemotherapy drug for breast cancer on the basis of cost effectiveness rather than effectiveness.

That’s right.  They will help you die, but not help you live…all based on the almighty dollar (or euro in the case of Britain)!

Let’s briefly examine this concept of “quality of life” for a moment.  I’ve asserted that it is highly subjective at its core.  At another statistics conference I attended in September, the keynote speaker was a Dr. Daniel Ariely who describes himself as a psychologist and behavioral economist.  His work provides some basis for my assertion.  When Dr. Ariely was a young man in the Israeli army, he was involved in an accident with a magnesium flare that went off next to him and left him with third degree burns (that’s black charred flesh) over 70% of his body and put him into the hospital for three years.  After his recovery and subsequent education, one of his first areas of research was in pain perception and tolerance.   Among other things, he’s demonstrated that it is not the duration of the pain that matters, rather it is the intensity of the pain that is critical.  Thus, slower, less painful stimuli are more readily handled than fast, very painful experiences (this line of experimentation was based on the daily changes of his burn bandages, an excruciating experience he had to withstand since his nurses were convinced that the fast ripping off of the bandages was the only way to endure the experience…not that any of them had actually experienced it themselves).  Interestingly enough, and more relevant to this post is his finding that individuals who have experienced episodes of intense pain such as he had (e.g., recovery from combat injuries or other burn patients) have a higher threshold for pain that those who had never experienced such intense pain before.  (No subjects were damaged by his research…I will let you get his books to figure out the details of how he did this, but it is all documented.)  Pain is directly related to one’s ability to function.  Try to execute what is for you a simple task when you have a splitting headache and you will realize the truth of this.

So, who is to say that any one person’s inability to, e.g., dress themselves, is an intolerable lowering of that person’s “quality of life” when they themselves have no problem being dressed by someone else if it let’s them have a life?  When the ability to withstand the discomfort of a disease varies from individual to individual, how is a threshold beyond which the alleged quality of life becomes unacceptable to be determined?

Which brings us to the despicable policies currently in place in Oregon of the good ole U. S. of A.  In my previous post, I copied the following from my source (emphases added):

A study published in the Journal of Internal Medicine last year, for example, found that doctors in Oregon write lethal prescriptions for patients who are not experiencing significant symptoms and that assisted suicide practice has had little do with any inability to alleviate pain – the fear of which is a chief selling point for legalisation.

The report said that family members described loved ones who pursue “physician-assisted death” as individuals for whom being in control is important, who anticipate the negative aspects of dying and who believe the impending loss of self and quality of life will be intolerable. They fear becoming a burden to others, yet want to die at home. Concerns about what may be experienced in the future were substantially more powerful reasons than what they experienced at that point in time.

When a scared and depressed patient asks for poison pills and their doctor’s response is to pull out the lethal prescription pad, it confirms the patient’s worst fears – that they are a burden, that they are less worth loving.

Did you get that?  These are the consequences of playing god with these kinds of decisions.  Unintended in some cases, perhaps, but nevertheless real.  My comments then are still appropriate:

Understand clearly, these are patients whose disease has not progressed to the point of imminent death. The possibility of cure has not been ruled out. Years of productive life are still a possibility, but because they are sick and know it, and have no control over it, they become depressed and dwell on all the problems involved rather than the opportunities that may present themselves. And apparently the fragmentation of the family and social structure of the immediate past has left them with no support from the family that should be cherishing and valuing their life and knowledge and wisdom, and communicating that with them so they understand the value their life has to others.

It is a sign of our present narcissistic culture that the only good in a situation is what might be good (and convenient) for me, and that “dignity” is defined as “doing it MY way,” and that goes for both the patient and the immediate family of the patient.

One of the keys to understanding this issue is in the last quote above. The issue of control, or rather, who is in control, is one that defines man’s pride. Man in his pride wants to be in control (cf. Psalm 2). Translation: man wants to play God with his life. This is the bioethical quandary over euthanasia. As the above instances show, it is usually not a matter of alleviating pain, but of convenience and the all too pragmatic issue of cost.

So, what is this true dignity with which we are exhorted to die? Oxford defines it as “the state or quality of being worthy of honor or respect.” Modern man has translated that into respecting the desire of one who wants to die…and then encouraging them to do so. But tell me, who do you really honor and respect more, someone who gives up and takes the easy way out, or someone who fights the good fight all the way to the end? For whom do you really have more respect, the one who essentially shoves their elderly relative under the rug, seeking to be rid of them as soon as possible so they can get on with their own freakin’ life, or the one who shows the strength of character to live sacrificially, taking care of another without thought of reward and “what’s in it for me?”

Self-centered pride utterly fails to see the benefit of tending to the needs of others and shrivels up into a caricature of what humanity is supposed to be.  Integrity and character of soul degenerate into the slough of selfish ambition when those who are weaker are cast aside.

Consider the young man in this YouTube video.  Born blind, the bean counters would undoubtedly say his quality of life is low.  But is it?  Watch and decide for yourself.

I dare say the quality of life of this young man is vastly greater than those lost souls who decide on the quality of life for others based on mere mathematical formulas divorced from the human reality of those whose lives are in their hands.  And I dare say his father’s life has been unbelievably enriched by his relationship with his son because he has unselfishly given himself to meeting his son’s needs.

My previous conclusion still holds here today and I will again close with it:

Where ultimately is the anchor by which to make such decisions? Only the Bible gives clear guidance on the value of life and on God’s right to make final decisions regarding our life expectancy. He appoints our days. All else is mere human hubris. If the selfish pragmatism noted above comes to rule the day, our society will truly be taking one more step into the oblivion of barbarism and away from true civilization.

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